Healthcare Provider Details

I. General information

NPI: 1730170663
Provider Name (Legal Business Name): LIBERTY HOME PHARMACY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8881 LIBERTY LN
PORT ST LUCIE FL
34952-3477
US

IV. Provider business mailing address

PO BOX 20003
FORT PIERCE FL
34979-0003
US

V. Phone/Fax

Practice location:
  • Phone: 877-891-2545
  • Fax: 877-891-2546
Mailing address:
  • Phone: 877-891-2545
  • Fax: 877-891-2546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT N MARK
Title or Position: PRESIDENT
Credential:
Phone: 772-398-5800