Healthcare Provider Details

I. General information

NPI: 1518086339
Provider Name (Legal Business Name): LIFELINE DIABETIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 3RD AVE N SUITE 1
AMORY MS
38821-3413
US

IV. Provider business mailing address

201 3RD AVE N
AMORY MS
38821-3413
US

V. Phone/Fax

Practice location:
  • Phone: 662-597-9200
  • Fax: 888-918-2226
Mailing address:
  • Phone: 662-597-9200
  • Fax: 888-918-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number08376/02.0
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MERRI SANDERSON
Title or Position: OWNER
Credential:
Phone: 662-597-9200