MEDICARE: SHOPRITE OF LIBERTY HEIGHTS, LLC

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

General Provider Information

NPI Number	:	1942620091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOPRITE OF LIBERTY HEIGHTS, LLC

Provider Business Mailing Address
First Line	:	2101 ROCK SPRING RD
Second Line	:
City	:	FOREST HILL
State	:	MD
Zip	:	21050-2617
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4601 LIBERTY HEIGHTS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-7553
Country	:	US
Telephone Number	:	410-666-1700
Fax Number	:

Authorized Official
Title or Position	:	THIRD PARTY ADMINISTRATOR
Name	:	MELISSA FIGUEROA RIVERA
Credential	:
Telephone Number	:	732-521-8439

Provider Enumeration Date	:	04/16/2014
Last Update Date	:	03/14/2016

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