Provider Demographics
NPI:1912217399
Name:KROGER SPECIALTY INFUSION TX, LLC
Entity Type:Organization
Organization Name:KROGER SPECIALTY INFUSION TX, LLC
Other - Org Name:KROGER SPECIALTY INFUSION TX
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 1:1748 N GREENVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75081-1808
Mailing Address - Country:US
Mailing Address - Phone:855-742-7690
Mailing Address - Fax:855-742-7689
Practice Address - Street 1:1748 N GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081
Practice Address - Country:US
Practice Address - Phone:855-742-7690
Practice Address - Fax:855-742-7689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X, 3336L0003X, 3336S0011X, 332BP3500X
TX272013336H0001X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX321000Medicaid
NM17125324Medicaid
KY7100683220Medicaid
CO9000154018Medicaid
OK200474300AOtherDME
OK200474300BMedicaid
TX217545703OtherDME / TPI
TX2175457-03Medicaid