Healthcare Provider Details

I. General information

NPI: 1386685261
Provider Name (Legal Business Name): PREMIER INFUSION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1761 DARTFORD DR
CORDOVA TN
38016-6497
US

IV. Provider business mailing address

1761 DARTFORD DR
CORDOVA TN
38016-6497
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-0520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1454937
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier06325305
Identifier TypeMEDICAID
Identifier StateMS
Identifier Issuer

VIII. Authorized Official

Name: MRS. CLINTONIA SIMMONS
Title or Position: PRESIDENT
Credential:
Phone: 901-219-3730