Provider Demographics
NPI:1043827694
Name:MEDLIFE SUPPLY LLC
Entity Type:Organization
Organization Name:MEDLIFE SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:877-401-2142
Mailing Address - Street 1:1495 FOREST HILL BLVD STE C1
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-6073
Mailing Address - Country:US
Mailing Address - Phone:877-401-2142
Mailing Address - Fax:561-770-3593
Practice Address - Street 1:1495 FOREST HILL BLVD STE C1
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-6073
Practice Address - Country:US
Practice Address - Phone:877-401-2142
Practice Address - Fax:561-770-3593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies