Provider Demographics
NPI:1730170663
Name:LIBERTY HOME PHARMACY CORPORATION
Entity type:Organization
Organization Name:LIBERTY HOME PHARMACY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-398-5800
Mailing Address - Street 1:PO BOX 20003
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34979-0003
Mailing Address - Country:US
Mailing Address - Phone:877-891-2545
Mailing Address - Fax:877-891-2546
Practice Address - Street 1:8881 LIBERTY LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-3477
Practice Address - Country:US
Practice Address - Phone:877-891-2545
Practice Address - Fax:877-891-2546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO73850080Medicaid
DE0001035416Medicaid
KY90002262Medicaid
AZ514902Medicaid
HI51901902Medicaid
IA0548313Medicaid
LA1268330Medicaid
AKMS383FLMedicaid
GA00864432AMedicaid
AKMS383FLMedicaid
IL=========002Medicaid