1598765570 NPI number — KROGER SPECIALTY PHARMACY, INC.

Table of content: (NPI 1598765570)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598765570 NPI number — KROGER SPECIALTY PHARMACY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KROGER SPECIALTY PHARMACY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KROGER SPECIALTY PHARMACY FL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598765570
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 LAKE EMMA RD UNIT 1000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE MARY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32746-3358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-733-3126
Provider Business Mailing Address Fax Number:
888-315-3270

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 LAKE EMMA RD UNIT 1000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE MARY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32746-3358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-733-3126
Provider Business Practice Location Address Fax Number:
888-315-3270
Provider Enumeration Date:
07/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
855-733-3126

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PH17230 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100246590A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1010381 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1531290 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598765570 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3087712 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 33321884 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500628537 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7038923 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1044873 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100166410 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7F7230 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008003029 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598765570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 582023 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9094202 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0018492980003 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003119890 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0541920 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1451031 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1598765570 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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