Provider Demographics
NPI:1306324686
Name:MEDLINE 1 LLC
Entity type:Organization
Organization Name:MEDLINE 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-268-8899
Mailing Address - Street 1:4440 LIVERPOOL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-7512
Mailing Address - Country:US
Mailing Address - Phone:901-268-8899
Mailing Address - Fax:
Practice Address - Street 1:4440 LIVERPOOL LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-7512
Practice Address - Country:US
Practice Address - Phone:901-268-8899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS837X0Medicaid