MEDICARE: LEGACY INFUSION SERVICES, 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	3336H0001X	Home Infusion Therapy Pharmacy	022051200	OH
2	251F00000X	Home Infusion Agency

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

General Provider Information

NPI Number	:	1164741377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY INFUSION SERVICES, LLC

Provider Business Mailing Address
First Line	:	1700 EDISON DR
Second Line	:	SUITE 300
City	:	MILFORD
State	:	OH
Zip	:	45150-2729
Country	:	US
Telephone Number	:	513-576-0262
Fax Number	:	513-576-0379

Provider Business Practice Location Address
First Line	:	9969 CINCINNATI DAYTON RD
Second Line	:
City	:	WEST CHESTER
State	:	OH
Zip	:	45069-3823
Country	:	US
Telephone Number	:	937-384-3873
Fax Number	:	513-942-2846

Authorized Official
Title or Position	:	VP, FINANCE AND CFO
Name	:	MR. WILLIAM S. HERDTNER
Credential	:
Telephone Number	:	513-576-0262

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	03/11/2015

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