Provider Demographics
NPI:1477631984
Name:LIBERTY DRUG INC
Entity Type:Organization
Organization Name:LIBERTY DRUG INC
Other - Org Name:LIBERTY DRUG INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOBI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEIDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-224-1204
Mailing Address - Street 1:315 W CHICKASHA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2652
Mailing Address - Country:US
Mailing Address - Phone:405-224-1204
Mailing Address - Fax:405-224-1208
Practice Address - Street 1:315 W CHICKASHA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2652
Practice Address - Country:US
Practice Address - Phone:405-224-1204
Practice Address - Fax:405-224-1208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18-4373336C0003X
3336L0003X
OK184373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072556OtherPK
OK100223170AMedicaid
3703130OtherOTHER ID NUMBER-COMMERCIAL NUMBER