Provider Demographics
NPI:1578671509
Name:MEDLEY VITAL CARE INFUSION, INC.
Entity Type:Organization
Organization Name:MEDLEY VITAL CARE INFUSION, INC.
Other - Org Name:MEDLEY VITAL CARE INFUSION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-437-3440
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:601 EAST HWY 28
Practice Address - Street 2:
Practice Address - City:OWENSVILLE
Practice Address - State:MO
Practice Address - Zip Code:65066
Practice Address - Country:US
Practice Address - Phone:573-437-3440
Practice Address - Fax:573-437-4963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005817332B00000X, 332BC3200X, 332BP3500X, 332BX2000X, 333600000X, 3336C0003X, 3336H0001X, 3336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
29836OtherBCBS
0722170001Medicare NSC
000049003Medicare ID - Type UnspecifiedLOCAL PART B