Provider Demographics
NPI:1184649782
Name:KROGER SPECIALTY PHARMACY, INC.
Entity type:Organization
Organization Name:KROGER SPECIALTY PHARMACY, INC.
Other - Org Name:<UNAVAIL>
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 1:1821 KAISER AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5707
Mailing Address - Country:US
Mailing Address - Phone:855-733-3126
Mailing Address - Fax:888-315-3270
Practice Address - Street 1:1821 KAISER AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5707
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:2006-07-13
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336M0002X
CAPHY515483336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM60000708Medicaid
WY140622100Medicaid
CA1184649782Medicaid
AK1626534Medicaid
CO94789061Medicaid
AZ092265Medicaid
WA2043938Medicaid
MT7176839Medicaid
UT1184649782Medicaid
ID1184649782Medicaid