MEDICARE: LIBERTY FAMILY 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	333600000X	Pharmacy

General Provider Information

NPI Number	:	1831533892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY FAMILY PHARMACY INC

Provider Business Mailing Address
First Line	:	8500 US HIGHWAY 158
Second Line	:	PO BOX 63
City	:	STOKESDALE
State	:	NC
Zip	:	27357-9248
Country	:	US
Telephone Number	:	336-644-7288
Fax Number	:

Provider Business Practice Location Address
First Line	:	430 N GREENSBORO ST
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-0000
Country	:	US
Telephone Number	:	336-644-7288
Fax Number	:	336-644-7291

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JIMMY DALE KEITH JR.
Credential	:	RPH MBA
Telephone Number	:	336-595-6979

Provider Enumeration Date	:	04/22/2013
Last Update Date	:	07/28/2015

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