NPIViewer - Provider NPI 1598765570

NPI:	1598765570
Name:	KROGER SPECIALTY PHARMACY, INC.
Entity Type:	Organization
Organization Name:	KROGER SPECIALTY PHARMACY, INC.
Other - Org Name:	KROGER SPECIALTY PHARMACY FL
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:	3200 LAKE EMMA RD UNIT 1000
Mailing Address - Street 2:
Mailing Address - City:	LAKE MARY
Mailing Address - State:	FL
Mailing Address - Zip Code:	32746-3358
Mailing Address - Country:	US
Mailing Address - Phone:	855-733-3126
Mailing Address - Fax:	888-315-3270
Practice Address - Street 1:	3200 LAKE EMMA RD UNIT 1000
Practice Address - Street 2:
Practice Address - City:	LAKE MARY
Practice Address - State:	FL
Practice Address - Zip Code:	32746-3358
Practice Address - Country:	US
Practice Address - Phone:	855-733-3126
Practice Address - Fax:	888-315-3270
EIN:	<UNAVAIL>
Is Organization Subpart?:	No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:	2005-07-29
Last Update Date:	2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
		332B00000X, 3336S0011X
FL	PH17230	333600000X

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

State	Identifier ID	ID Type
OK	100246590A	Medicaid
VT	1010381	Medicaid
TN	1531290	Medicaid
MN	1598765570	Medicaid
NH	3087712	Medicaid
CO	33321884	Medicaid
OR	500628537	Medicaid
MT	7038923	Medicaid
WA	1044873	Medicaid
KY	7100166410	Medicaid
SC	7F7230	Medicaid
CT	008003029	Medicaid
CA	1598765570	Medicaid
TX	582023	Medicaid
NJ	9094202	Medicaid
PA	0018492980003	Medicaid
CT	003119890	Medicaid
IA	0541920	Medicaid
ND	1451031	Medicaid
ME	1598765570	Medicaid
MI	1598765570	Medicaid
OH	2207678	Medicaid
MD	416817800	Medicaid
FL	0022363802	Medicaid
FL	022363800	Medicaid
MT	0270686	Medicaid
NY	03105699	Medicaid
AK	1028738	Medicaid
ID	1598765570	Medicaid
NC	1598765570	Medicaid
DC	057055900	Medicaid
IN	200297170A	Medicaid
OR	500626260	Medicaid
MD	094403300	Medicaid
OK	100246590B	Medicaid
KS	100444750A	Medicaid
WY	115772800	Medicaid
VA	1598765570	Medicaid
AZ	536089	Medicaid
NV	1598765570	Medicaid
SC	DM1317	Medicaid