Provider Demographics
NPI:1518086339
Name:LIFELINE DIABETIC
Entity Type:Organization
Organization Name:LIFELINE DIABETIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-597-9200
Mailing Address - Street 1:201 3RD AVE N
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-3413
Mailing Address - Country:US
Mailing Address - Phone:662-597-9200
Mailing Address - Fax:888-918-2226
Practice Address - Street 1:201 3RD AVE N
Practice Address - Street 2:SUITE 1
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-3413
Practice Address - Country:US
Practice Address - Phone:662-597-9200
Practice Address - Fax:888-918-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08376/02.0332B00000X
333600000X, 3336M0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2587977OtherNCPDP PROVIDER IDENTIFICATION NUMBER
2587977OtherNCPDP PROVIDER IDENTIFICATION NUMBER