Provider Demographics
NPI:1093444911
Name:1ST AMERICA INFUSION SERVICES LLC
Entity Type:Organization
Organization Name:1ST AMERICA INFUSION SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDERAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-482-8466
Mailing Address - Street 1:623 HIGHLAND COLONY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6077
Mailing Address - Country:US
Mailing Address - Phone:601-988-1700
Mailing Address - Fax:866-204-7069
Practice Address - Street 1:212 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1858
Practice Address - Country:US
Practice Address - Phone:229-242-3060
Practice Address - Fax:229-242-9914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA323764040AMedicaid
2019860OtherPK