1730170663 NPI number — LIBERTY HOME PHARMACY CORPORATION

Table of content: (NPI 1730170663)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730170663 NPI number — LIBERTY HOME PHARMACY CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HOME PHARMACY CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730170663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 20003
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34979-0003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-891-2545
Provider Business Mailing Address Fax Number:
877-891-2546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8881 LIBERTY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT ST LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34952-3477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-891-2545
Provider Business Practice Location Address Fax Number:
877-891-2546
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARK
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-398-5800

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 73850080 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001035416 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 90002262 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 514902 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51901902 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0548313 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1268330 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: MS383FL , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00864432A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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