Provider Demographics
NPI:1033135983
Name:KROGER SPECIALTY INFUSION CA, LLC
Entity Type:Organization
Organization Name:KROGER SPECIALTY INFUSION CA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-733-3126
Mailing Address - Street 1:19110 VAN NESS AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-1101
Mailing Address - Country:US
Mailing Address - Phone:310-320-6444
Mailing Address - Fax:866-794-4844
Practice Address - Street 1:19110 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501-1101
Practice Address - Country:US
Practice Address - Phone:310-320-6444
Practice Address - Fax:866-794-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
CAPHY546493336C0003X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201249880AMedicaid
NJ0643688Medicaid
OK200520480AMedicaid
TNQ035652Medicaid
MN1033135983Medicaid
WA2034743Medicaid
AZ315377Medicaid
KY7100285000Medicaid
CA1033135983Medicaid
OR500671966Medicaid
CO9000151429Medicaid
OR500671966Medicaid