Provider Demographics
NPI:1063424208
Name:LIBERMAN, JEFFREY (RPH)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:LIBERMAN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SYCAMORE DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576-2421
Mailing Address - Country:US
Mailing Address - Phone:516-484-9009
Mailing Address - Fax:516-625-5469
Practice Address - Street 1:15840 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-3136
Practice Address - Country:US
Practice Address - Phone:718-738-4343
Practice Address - Fax:718-845-1420
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893792Medicaid
NY1174520779OtherSTORE NPI #
NY3382835OtherSTORE NABP #
NY018639OtherNYS LISCENSE #
NY018639OtherNYS LISCENSE #
NY018639OtherNYS LISCENSE #