Basic Information
Provider Information | |||||||||
NPI: | 1417969882 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED INFUSION SYSTEMS, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PHARMERICA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3802 CORPOREX PARK DR | ||||||||
Address2: | STE 200 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336191125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8133186039 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1214 N MARKET BLVD | ||||||||
Address2: | SUITE C | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958341906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9169283830 | ||||||||
FaxNumber: | 9169281375 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 10/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REED | ||||||||
AuthorizedOfficialFirstName: | STEVEN | ||||||||
AuthorizedOfficialMiddleName: | S. | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 5023942100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHARMERICA CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 3336L0003X | PHY44486 | CA | N |   | Suppliers | Pharmacy | Long Term Care Pharmacy | 3336L0003X | PHY48703 | CA | Y |   | Suppliers | Pharmacy | Long Term Care Pharmacy |
ID Information
ID | Type | State | Issuer | Description | PHA444860 | 05 | CA |   | MEDICAID | 1417969882 | 05 | NV |   | MEDICAID | 1417969882 | 05 | CA |   | MEDICAID |