Provider Demographics
NPI:1710043088
Name:LIEB PHARMACY INC
Entity Type:Organization
Organization Name:LIEB PHARMACY INC
Other - Org Name:LIEB PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAOUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMANTSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-633-5770
Mailing Address - Street 1:5006 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1404
Mailing Address - Country:US
Mailing Address - Phone:718-633-5770
Mailing Address - Fax:718-633-5772
Practice Address - Street 1:5006 16TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-1404
Practice Address - Country:US
Practice Address - Phone:718-633-5770
Practice Address - Fax:718-633-5772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
NY0190503336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00981071Medicaid
2064378OtherPK
5031650001Medicare NSC