KROGER SPECIALTY PHARMACY FL 2 LLC

Provider Demographics

• NPI: 1508146010
• Name: KROGER SPECIALTY PHARMACY FL 2 LLC
• Entity Type: Organization
• Organization Name: KROGER SPECIALTY PHARMACY FL 2 LLC
• Other - Org Name: KROGER SPECIALTY PHARMACY FL 2
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: VICE PRESIDENT
• Authorized Official - First Name: DEBRA
• Authorized Official - Middle Name: J
• Authorized Official - Last Name: COLE
• Authorized Official - Phone: 855-733-3126
• Mailing Address - Street 1: 6435 HAZELTINE NATIONAL DR STE 140
• Mailing Address - City: ORLANDO
• Mailing Address - State: FL
• Mailing Address - Zip Code: 32822-5156
• Mailing Address - Country: US
• Mailing Address - Phone: 855-274-1694
• Mailing Address - Fax: 855-819-6922
• Practice Address - Street 1: 6435 HAZELTINE NATIONAL DR STE 140
• Practice Address - City: ORLANDO
• Practice Address - State: FL
• Practice Address - Zip Code: 32822-5156
• Practice Address - Country: US
• Practice Address - Phone: 855-274-1694
• Practice Address - Fax: 855-819-6922
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2011-08-29
• Last Update Date: 2020-09-30

Provider Licenses

State	License ID	Taxonomies
		332B00000X, 333600000X, 3336C0003X
FL	PH25629	3336S0011X, 3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	333600000X	Suppliers	Pharmacy
No	3336C0003X	Suppliers	Pharmacy	Community/Retail Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
FL	004264401	Medicaid
MT	0406939	Medicaid
AZ	097296	Medicaid
NV	1508146010	Medicaid
KS	201116160B	Other	KANSAS (P) (CHILDREN WITH SPECIAL HEALTHCARE NEEDS)
VA	2049652	Medicaid
TN	Q036221	Medicaid
GA	003131027B	Medicaid
FL	004264400	Medicaid
NJ	0506711	Medicaid
WI	1508146010	Medicaid
MI	1508146010	Medicaid
NM	16221397	Medicaid
FL	163522375	Medicaid
OR	500687694	Medicaid
KY	7100257570	Other	KENTUCKY (P), PASSPORT HEALTH PLAN, WELLCARE OF KENTUCKY
NE	100264920-00	Medicaid
PA	103011190-0001	Medicaid
FL	1508146010	Other	FLORIDA CHILDREN'S MEDICAL SERVICES
UT	1508146010	Medicaid
KY	18-20-CC-9559	Other	KENTUCKY (CHILDREN WITH SPECIAL HEALTH CARE NEEDS)
OK	200590550A	Other	OKLAHOMA (P) CHILDREN WITH SPECIAL HEALTHCARE NEEDS PROGRAM VENDOR
KS	201116160A	Other	KANSAS (QMB)
CO	64770109	Medicaid
GA	003131027A	Medicaid
IA	0212596	Medicaid
VA	1508146010	Medicaid
ID	1508146010	Medicaid
ID	Q036221	Other	IDAHO (P) (CHILDREN WITH SPECIAL HEALTHCARE NEEDS)
MT	0406827	Medicaid
IN	1508146010	Other	INDIANA CHILDREN'S SPECIAL HEALTH CARE SERVICES PROGRAM
MO	1508146010	Medicaid
	2131644	Other	PK
NH	3102337	Medicaid
NH	3106044	Medicaid
MD	150015500	Medicaid
AL	216017	Medicaid
VT	1025997	Medicaid
IN	201121900A	Medicaid
NM	27828701	Medicaid
SC	7F5629	Medicaid
SC	DM1542	Medicaid
NJ	0518565	Medicaid
KY	15-17-CC-9559	Other	KENTUCKY (CHILDREN WITH SPECIAL HEALTH CARE NEEDS)
NC	1508146010	Medicaid
MN	1508146010	Medicaid
OR	500686927	Medicaid