Provider Demographics
NPI:1346210549
Name:KROGER SPECIALTY INFUSION AL, LLC
Entity Type:Organization
Organization Name:KROGER SPECIALTY INFUSION AL, LLC
Other - Org Name:KROGER SPECIALTY INFUSION AL
Other - Org Type:Doing Business As
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 1:2511 ROSS CLARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301
Mailing Address - Country:US
Mailing Address - Phone:334-794-1126
Mailing Address - Fax:334-793-0592
Practice Address - Street 1:2511 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4912
Practice Address - Country:US
Practice Address - Phone:334-794-1126
Practice Address - Fax:334-793-0592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
AL1107393336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009920285Medicaid
FL031036100Medicaid
GA003188543AMedicaid
1993756OtherPK
FL031036101Medicaid
AL100003469Medicaid
GA003159485BMedicaid
AL100003469Medicaid