Basic Information
| Provider Information | |||||||||
| NPI: | 1164741377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LEGACY INFUSION SERVICES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 EDISON DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MILFORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451502729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135760262 | ||||||||
| FaxNumber: | 5135760379 | ||||||||
| Practice Location | |||||||||
| Address1: | 9969 CINCINNATI DAYTON RD | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450693823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373843873 | ||||||||
| FaxNumber: | 5139422846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 03/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | HERDTNER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135760262 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336H0001X | 022051200 | OH | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 251F00000X | Y | Agencies | Home Infusion |
ID Information
| ID | Type | State | Issuer | Description | 3134101 | 05 | OH | MEDICAID |