MEDICARE: INFUSION PRN LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336H0001X	Home Infusion Therapy Pharmacy	0201004420	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4844076	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1558635755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INFUSION PRN LLC

Provider Business Mailing Address
First Line	:	4953 COX RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6296
Country	:	US
Telephone Number	:	804-888-8630
Fax Number	:	804-888-8628

Provider Business Practice Location Address
First Line	:	4953 COX RD
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23060-6296
Country	:	US
Telephone Number	:	804-888-8630
Fax Number	:	804-888-8628

Authorized Official
Title or Position	:	EVP/COO
Name	:	TAMARA EISELE
Credential	:
Telephone Number	:	804-747-8900

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	08/21/2012

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Directions to “INFUSION PRN LLC ” Practice Location

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