Provider Demographics
NPI:1215657903
Name:1ST AMERICA INFUSION SERVICES LLC
Entity type:Organization
Organization Name:1ST AMERICA INFUSION SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUDERAL
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-482-8466
Mailing Address - Street 1:623 HIGHLAND COLONY PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6077
Mailing Address - Country:US
Mailing Address - Phone:769-300-0803
Mailing Address - Fax:866-204-7069
Practice Address - Street 1:10 WARREN RD STE 220
Practice Address - Street 2:
Practice Address - City:COCKEYSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21030-2531
Practice Address - Country:US
Practice Address - Phone:833-607-2874
Practice Address - Fax:866-204-7069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-01
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP08643OtherPK
MD212184101Medicaid