MEDICARE: LIFELINE INFUSION SERVICES, INC.

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	3336S0011X	Specialty Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy
4	3336H0001X	Home Infusion Therapy Pharmacy	021626	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2063801	OTHER		PK

General Provider Information

NPI Number	:	1982639530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE INFUSION SERVICES, INC.

Provider Business Mailing Address
First Line	:	559 MIDDLE RD
Second Line	:
City	:	BAYPORT
State	:	NY
Zip	:	11705-1931
Country	:	US
Telephone Number	:	631-472-2929
Fax Number	:	631-472-6882

Provider Business Practice Location Address
First Line	:	559 MIDDLE RD
Second Line	:
City	:	BAYPORT
State	:	NY
Zip	:	11705-1931
Country	:	US
Telephone Number	:	631-472-2929
Fax Number	:	631-472-6882

Authorized Official
Title or Position	:	SECRETARY/TREASURER
Name	:	RUSSELL MARTIN
Credential	:
Telephone Number	:	631-472-2929

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	08/15/2016

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