Healthcare Provider Details

I. General information

NPI: 1477631984
Provider Name (Legal Business Name): LIBERTY DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W CHICKASHA AVE
CHICKASHA OK
73018-2652
US

IV. Provider business mailing address

315 W CHICKASHA AVE
CHICKASHA OK
73018-2652
US

V. Phone/Fax

Practice location:
  • Phone: 405-224-1204
  • Fax: 405-224-1208
Mailing address:
  • Phone: 405-224-1204
  • Fax: 405-224-1208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number18-437
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TOBI NEIDY
Title or Position: MANAGER
Credential:
Phone: 405-224-1204