Provider Demographics
NPI:1093075236
Name:LIBERTY PHARMACY INC.
Entity Type:Organization
Organization Name:LIBERTY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AYESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FURQUAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-738-1500
Mailing Address - Street 1:12402A LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11419-2232
Mailing Address - Country:US
Mailing Address - Phone:718-738-1500
Mailing Address - Fax:
Practice Address - Street 1:12402A LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-2232
Practice Address - Country:US
Practice Address - Phone:718-738-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031201333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031201OtherNYS PHARMACY LICENSE