Healthcare Provider Details

I. General information

NPI: 1417310178
Provider Name (Legal Business Name): INNOVATIVE INFUSION SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S BROADWAY AVE #114
WICHITA KS
67202-3900
US

IV. Provider business mailing address

505 S BROADWAY AVE #114
WICHITA KS
67202-3900
US

V. Phone/Fax

Practice location:
  • Phone: 316-200-5605
  • Fax: 316-272-9141
Mailing address:
  • Phone: 316-613-8942
  • Fax: 316-272-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number2-13252
License Number StateKS

VIII. Authorized Official

Name: MR. BRIEN NICHOLAS BOYD
Title or Position: CO-OWNER
Credential:
Phone: 316-613-8942