Provider Demographics
NPI:1326143603
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:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:HANNA
Authorized Official - Last Name:ESHO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-841-1990
Mailing Address - Street 1:4802 W VERNOR HWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48209-2122
Mailing Address - Country:US
Mailing Address - Phone:313-841-1990
Mailing Address - Fax:313-841-6966
Practice Address - Street 1:4802 W VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2122
Practice Address - Country:US
Practice Address - Phone:313-841-1990
Practice Address - Fax:313-941-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010064383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3272800Medicaid
MI0H22563OtherBLUE CROSS BLUE SHIELD
MI3272292Medicaid
MI3272800Medicaid