Provider Demographics
NPI:1801611280
Name:LIBERTY DRUG LLC
Entity type:Organization
Organization Name:LIBERTY DRUG LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCHANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:983-204-1050
Mailing Address - Street 1:497 W 4800 S STE 100
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-4749
Mailing Address - Country:US
Mailing Address - Phone:801-810-0337
Mailing Address - Fax:
Practice Address - Street 1:2095 W 6TH AVE STE 114
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1879
Practice Address - Country:US
Practice Address - Phone:801-810-0337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-20
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy