Provider Demographics
NPI:1982639530
Name:LIFELINE INFUSION SERVICES, INC.
Entity Type:Organization
Organization Name:LIFELINE INFUSION SERVICES, INC.
Other - Org Name:LIFELINE INFUSION SVCS INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-472-2929
Mailing Address - Street 1:559 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1931
Mailing Address - Country:US
Mailing Address - Phone:631-472-2929
Mailing Address - Fax:631-472-6882
Practice Address - Street 1:559 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1931
Practice Address - Country:US
Practice Address - Phone:631-472-2929
Practice Address - Fax:631-472-6882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
NY0216263336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420626Medicaid
2063801OtherPK
07550Medicare PIN
2063801OtherPK
3343958OtherNCPDP PROVIDER IDENTIFICATION NUMBER