Provider Demographics
NPI:1154805042
Name:LIBERATISCIOLI, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:LIBERATISCIOLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 TOWNSEDGE DR
Mailing Address - Street 2:
Mailing Address - City:QUARRYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17566-1300
Mailing Address - Country:US
Mailing Address - Phone:717-786-1191
Mailing Address - Fax:
Practice Address - Street 1:112 TOWNSEDGE DR
Practice Address - Street 2:
Practice Address - City:QUARRYVILLE
Practice Address - State:PA
Practice Address - Zip Code:17566-1300
Practice Address - Country:US
Practice Address - Phone:717-786-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP444693183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP444693OtherPHARMACIST LICENSE
PARPI005529OtherAUTHORIZATION TO ADMINISTER INJECTABLES