MEDICARE: LIBERTY PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	PH25059	FL

General Provider Information

NPI Number	:	1073815106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY PHARMACY LLC

Provider Business Mailing Address
First Line	:	5443 N FEDERAL HWY
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-3206
Country	:	US
Telephone Number	:	954-543-2991
Fax Number	:

Provider Business Practice Location Address
First Line	:	5443 N FEDERAL HWY
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33308-3206
Country	:	US
Telephone Number	:	954-543-2991
Fax Number	:

Authorized Official
Title or Position	:	MGR
Name	:	JEFFERSON HENN
Credential	:
Telephone Number	:	954-543-2991

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	11/22/2010

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Directions to “LIBERTY PHARMACY LLC ” Practice Location

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