Provider Demographics
NPI:1275091373
Name:PRIME LIBERTY PHARMACY INC
Entity Type:Organization
Organization Name:PRIME LIBERTY PHARMACY INC
Other - Org Name:PRIME LIBERTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/CFO/SEC/DIR
Authorized Official - Prefix:
Authorized Official - First Name:HASMIK
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVSHENIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-465-3515
Mailing Address - Street 1:7335 VAN NUYS BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-1951
Mailing Address - Country:US
Mailing Address - Phone:818-465-3515
Mailing Address - Fax:818-465-3514
Practice Address - Street 1:7335 VAN NUYS BLVD STE 107
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1951
Practice Address - Country:US
Practice Address - Phone:818-465-3515
Practice Address - Fax:818-465-3514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-07
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy