Provider Demographics
NPI:1881698439
Name:LIBERATOR MEDICAL SUPPLY, INC.
Entity type:Organization
Organization Name:LIBERATOR MEDICAL SUPPLY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TARIQ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-323-0914
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0446
Mailing Address - Country:US
Mailing Address - Phone:800-323-0914
Mailing Address - Fax:877-730-7796
Practice Address - Street 1:1823 SE AIRPORT RD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34996-4012
Practice Address - Country:US
Practice Address - Phone:800-323-0914
Practice Address - Fax:877-730-7796
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIBERATOR MEDICAL HOLDINGS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-10
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHME372332B00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027541700Medicaid
2130872OtherPK