MEDICARE: LALIBELA, LTD

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	PP482640	PA

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	:	1891140489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LALIBELA, LTD

Provider Business Mailing Address
First Line	:	9892 BUSTLETON AVE STE 102
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-2138
Country	:	US
Telephone Number	:	267-939-8449
Fax Number	:	215-560-8996

Provider Business Practice Location Address
First Line	:	9892 BUSTLETON AVE STE 102
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19115-2138
Country	:	US
Telephone Number	:	215-315-8980
Fax Number	:	215-315-8984

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YAKOV BEREZHINSKY
Credential	:
Telephone Number	:	267-226-6896

Provider Enumeration Date	:	05/02/2016
Last Update Date	:	06/05/2025

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