Provider Demographics
NPI:1265625990
Name:LIBRA HEALTHCARE LLC
Entity type:Organization
Organization Name:LIBRA HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:1232 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4009
Mailing Address - Country:US
Mailing Address - Phone:386-238-3777
Mailing Address - Fax:386-238-3343
Practice Address - Street 1:1232 8TH ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4009
Practice Address - Country:US
Practice Address - Phone:386-238-3777
Practice Address - Fax:386-238-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X, 3336C0004X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPH22899OtherSTATE LICENSE
FL1028112OtherNCPDP
FL1028112OtherNCPDP
FL6043960001Medicare NSC