Provider Demographics
NPI:1598215840
Name:KROGER PHARMACY
Entity Type:Organization
Organization Name:KROGER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:RHONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-795-9966
Mailing Address - Street 1:1105 ISLAND PARK BLVD
Mailing Address - Street 2:714
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4741
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6652 YOUREE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4630
Practice Address - Country:US
Practice Address - Phone:318-795-9966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KROGER COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0216933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy