Provider Demographics
NPI:1962648261
Name:LIBERTY HEALTHCARE PHARMACY OF NEVADA LLC
Entity Type:Organization
Organization Name:LIBERTY HEALTHCARE PHARMACY OF NEVADA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-5800
Mailing Address - Street 1:8881 LIBERTY LN
Mailing Address - Street 2:ATTN;COMPLIANCE
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-3477
Mailing Address - Country:US
Mailing Address - Phone:772-398-5800
Mailing Address - Fax:772-398-2192
Practice Address - Street 1:6225 ANNIE OAKLEY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3914
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 HEALTHCARE GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH022043336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVPH02204OtherRESIDENT PHARMACY LICENSE
2991520OtherNCPDP
2991520OtherNCPDP