MEDICARE: LIBERTY AVE PHARMACY,INC

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	3336C0003X	Community/Retail Pharmacy	024286	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669508818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY AVE PHARMACY,INC

Provider Business Mailing Address
First Line	:	1108 LIBERTY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-2922
Country	:	US
Telephone Number	:	718-827-7528
Fax Number	:	718-277-0193

Provider Business Practice Location Address
First Line	:	1108 LIBERTY AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-2922
Country	:	US
Telephone Number	:	718-827-7528
Fax Number	:	718-277-0193

Authorized Official
Title or Position	:	SP
Name	:	MR. ABU S AZAM
Credential	:	RPH.
Telephone Number	:	718-827-7528

Provider Enumeration Date	:	02/24/2007
Last Update Date	:	08/22/2020

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