Healthcare Provider Details

I. General information

NPI: 1710043088
Provider Name (Legal Business Name): LIEB PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5006 16TH AVE
BROOKLYN NY
11204-1404
US

IV. Provider business mailing address

5006 16TH AVE
BROOKLYN NY
11204-1404
US

V. Phone/Fax

Practice location:
  • Phone: 718-633-5770
  • Fax: 718-633-5772
Mailing address:
  • Phone: 718-633-5770
  • Fax: 718-633-5772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number019050
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RAOUL DIAMANTSTEIN
Title or Position: PRESIDENT
Credential: RPH
Phone: 718-633-5770