Provider Demographics
NPI:1144406703
Name:LIBERTY COMPOUNDING PHARMACY, LLC
Entity Type:Organization
Organization Name:LIBERTY COMPOUNDING PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-847-8888
Mailing Address - Street 1:7355 LEWIS AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182
Mailing Address - Country:US
Mailing Address - Phone:734-847-8888
Mailing Address - Fax:734-847-8884
Practice Address - Street 1:7355 LEWIS AVE
Practice Address - Street 2:SUITE D
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182
Practice Address - Country:US
Practice Address - Phone:734-847-8888
Practice Address - Fax:734-847-8884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010087803336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy