MEDICARE: LIEB 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	3336L0003X	Long Term Care Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	019050	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
2	2064378	OTHER		PK

General Provider Information

NPI Number	:	1710043088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIEB PHARMACY INC

Provider Business Mailing Address
First Line	:	5006 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1404
Country	:	US
Telephone Number	:	718-633-5770
Fax Number	:	718-633-5772

Provider Business Practice Location Address
First Line	:	5006 16TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1404
Country	:	US
Telephone Number	:	718-633-5770
Fax Number	:	718-633-5772

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RAOUL DIAMANTSTEIN
Credential	:	RPH
Telephone Number	:	718-633-5770

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	02/20/2017

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Directions to “LIEB PHARMACY INC ” Practice Location

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