Healthcare Provider Details

I. General information

NPI: 1720689037
Provider Name (Legal Business Name): TIFFANY LIEBERTH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 DARROW RD
STOW OH
44224-4050
US

IV. Provider business mailing address

3000 WEXFORD BLVD
STOW OH
44224-2850
US

V. Phone/Fax

Practice location:
  • Phone: 330-686-5285
  • Fax:
Mailing address:
  • Phone: 330-592-9160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03-3-19973
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: