Provider Demographics
NPI:1639562820
Name:KROGER
Entity Type:Organization
Organization Name:KROGER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY CLINICAL COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LORD
Authorized Official - Middle Name:
Authorized Official - Last Name:SARINO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:310-884-4733
Mailing Address - Street 1:16325 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2101
Mailing Address - Country:US
Mailing Address - Phone:818-728-4515
Mailing Address - Fax:
Practice Address - Street 1:16325 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2101
Practice Address - Country:US
Practice Address - Phone:818-728-4515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50440261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center