Provider Demographics
NPI:1073815106
Name:LIBERTY PHARMACY LLC
Entity Type:Organization
Organization Name:LIBERTY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-543-2991
Mailing Address - Street 1:5443 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3206
Mailing Address - Country:US
Mailing Address - Phone:954-543-2991
Mailing Address - Fax:
Practice Address - Street 1:5443 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3206
Practice Address - Country:US
Practice Address - Phone:954-543-2991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH25059333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy