=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831533892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY FAMILY PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2013
-----------------------------------------------------
Last Update Date | 07/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 N GREENSBORO ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27298-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-644-7288
-----------------------------------------------------
Fax | 336-644-7291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8500 US HIGHWAY 158 PO BOX 63
-----------------------------------------------------
City | STOKESDALE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27357-9248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-644-7288
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JIMMY DALE KEITH JR.
-----------------------------------------------------
Credential | RPH MBA
-----------------------------------------------------
Telephone | 336-595-6979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------