Provider Demographics
NPI:1649223165
Name:INFINITY PHARMACY LLC
Entity Type:Organization
Organization Name:INFINITY PHARMACY LLC
Other - Org Name:INFINITY PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CASAL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:931-520-1001
Mailing Address - Street 1:1080 NEAL ST
Mailing Address - Street 2:STE 100
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0942
Mailing Address - Country:US
Mailing Address - Phone:931-520-1001
Mailing Address - Fax:931-520-1345
Practice Address - Street 1:1080 NEAL ST
Practice Address - Street 2:STE 100
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0942
Practice Address - Country:US
Practice Address - Phone:931-520-1001
Practice Address - Fax:931-520-1345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
TN00000042753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095014OtherPK
TN1510342Medicaid
TN1510342Medicaid
TN25610OtherPHARMACIST LICENSE
TN5722940001Medicare NSC
TN4275OtherPHARMACY LICENSE
TN1510342Medicaid