Provider Demographics
NPI:1649413832
Name:LIBERTY MEDICAL, LLC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-5800
Mailing Address - Street 1:8881 LIBERTY LN
Mailing Address - Street 2:ATTN: LICENSING
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3477
Mailing Address - Country:US
Mailing Address - Phone:772-398-5800
Mailing Address - Fax:844-363-4341
Practice Address - Street 1:8881 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3477
Practice Address - Country:US
Practice Address - Phone:800-491-3276
Practice Address - Fax:877-592-8466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERTY MEDICAL HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH288763336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1045118OtherNCPDP
FLPH28876OtherRESIDENT BOARD OF PHARMACY LICENSE
FLPH28876OtherRESIDENT BOARD OF PHARMACY LICENSE
FL 5112470OtherDEA