Healthcare Provider Details

I. General information

NPI: 1629933692
Provider Name (Legal Business Name): LIBERTY COMPOUNDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 PARK CENTRE BLVD STE 136
MIAMI FL
33169-5373
US

IV. Provider business mailing address

1000 PARK CENTRE BLVD STE 136
MIAMI FL
33169-5373
US

V. Phone/Fax

Practice location:
  • Phone: 602-705-6631
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. NICHOLAS VENTURA
Title or Position: HEAD OF PHARMACY
Credential:
Phone: 602-705-6631