Healthcare Provider Details

I. General information

NPI: 1750873535
Provider Name (Legal Business Name): LIBERTY PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 W VERNOR HWY
DETROIT MI
48209-2122
US

IV. Provider business mailing address

4802 W VERNOR HWY
DETROIT MI
48209-2122
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-1990
  • Fax: 313-841-6966
Mailing address:
  • Phone: 313-841-1990
  • Fax: 313-841-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301006438
License Number StateMI

VIII. Authorized Official

Name: GOERGE ESHO
Title or Position: PRESIDENT
Credential:
Phone: 313-841-1990