MEDICARE: REBECCA LYNN LIEBEGOTT

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	183500000X	Pharmacist	RP452669	PA

General Provider Information

NPI Number	:	1588148159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA LYNN LIEBEGOTT

Provider Business Mailing Address
First Line	:	8079 N MAIN ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1118
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8079 N MAIN ST
Second Line	:
City	:	EDEN
State	:	NY
Zip	:	14057-1118
Country	:	US
Telephone Number	:	716-992-9734
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2018
Last Update Date	:	12/10/2022

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