Provider Demographics
NPI:1861503989
Name:LIBERTY PHARMACY, INC
Entity Type:Organization
Organization Name:LIBERTY PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPH/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:MAYS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:931-729-3541
Mailing Address - Street 1:PO BOX 258
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-0258
Mailing Address - Country:US
Mailing Address - Phone:931-729-3541
Mailing Address - Fax:931-729-4874
Practice Address - Street 1:1518 HIGHWAY 100 STE 100
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1182
Practice Address - Country:US
Practice Address - Phone:931-729-3541
Practice Address - Fax:931-729-4874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3513015Medicaid
TN0225040001Medicare NSC