Provider Demographics
NPI:1689987117
Name:LEIBERMAN, STANLEY
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:LEIBERMAN
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 1:429 LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1544
Mailing Address - Country:US
Mailing Address - Phone:207-774-7719
Mailing Address - Fax:
Practice Address - Street 1:429 LUDLOW ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1544
Practice Address - Country:US
Practice Address - Phone:207-774-7719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR2865183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist