Provider Demographics
NPI:1326684424
Name:LIU, WILL RUSSELL
Entity Type:Individual
Prefix:
First Name:WILL
Middle Name:RUSSELL
Last Name:LIU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 W ATLANTIC BLVD
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5296
Mailing Address - Country:US
Mailing Address - Phone:954-975-5131
Mailing Address - Fax:954-975-5568
Practice Address - Street 1:5555 W ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5296
Practice Address - Country:US
Practice Address - Phone:954-975-5131
Practice Address - Fax:954-975-5568
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37659183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist