Provider Demographics
NPI:1881655330
Name:LIBERTY MEDICAL, LLC
Entity Type:Organization
Organization Name:LIBERTY MEDICAL, LLC
Other - Org Name:APTIVA MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNZWEILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-5800
Mailing Address - Street 1:5249 NW 33RD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-6302
Mailing Address - Country:US
Mailing Address - Phone:772-398-5800
Mailing Address - Fax:
Practice Address - Street 1:5249 NW 33RD AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-6302
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:ARX HOLDINGS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
333600000X, 3336M0002X, 3336S0011X
FLPH288763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
10-86493OtherNABP/NCPDP
FLPH28876OtherRESIDENT BOARD OF PHARMACY LICENSE
FL5112470OtherDEA
FL5112470OtherDEA
MD168302100Medicaid
KY7100201520Medicaid
FLPH16634OtherRESIDENT-STATE PHARMACY LICENSE
ID1881655330Medicaid
2012497OtherPK
BL-6408531OtherDEA
NM00068393Medicaid
NH3092228Medicaid
10-86493OtherNABP/NCPDP
OK100800030BMedicaid
ME1881655330Medicaid
WA1881655330Medicaid
IN1881655330Medicaid
0333860004Medicare NSC