Provider Demographics
NPI:1013913458
Name:KROGER SPECIALTY PHARMACY CA, LLC
Entity Type:Organization
Organization Name:KROGER SPECIALTY PHARMACY CA, LLC
Other - Org Name:
Other - Org Type:
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 1:7373 LINCOLN WAY
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841
Mailing Address - Country:US
Mailing Address - Phone:714-622-6700
Mailing Address - Fax:866-539-1092
Practice Address - Street 1:7373 LINCOLN WAY
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-1428
Practice Address - Country:US
Practice Address - Phone:714-622-6700
Practice Address - Fax:866-539-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BP3500X, 333600000X
CAPHY546483336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO24079073Medicaid
CA1013913458Medicaid
NM35356383Medicaid
OR500739393Medicaid
AZ825265Medicaid