1508146010 NPI number — KROGER SPECIALTY PHARMACY FL 2 LLC

Table of content: (NPI 1508146010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508146010 NPI number — KROGER SPECIALTY PHARMACY FL 2 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KROGER SPECIALTY PHARMACY FL 2 LLC
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 2
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:
1508146010
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:
6435 HAZELTINE NATIONAL DR STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32822-5156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
855-274-1694
Provider Business Mailing Address Fax Number:
855-819-6922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6435 HAZELTINE NATIONAL DR STE 140
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32822-5156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-274-1694
Provider Business Practice Location Address Fax Number:
855-819-6922
Provider Enumeration Date:
08/29/2011

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X , with the licence number: PH25629 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004264401 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0406939 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 097296 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1508146010 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201116160B . This is a "KANSAS (P) (CHILDREN WITH SPECIAL HEALTHCARE NEEDS)" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 2049652 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: Q036221 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 003131027B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004264400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0506711 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1508146010 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1508146010 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 16221397 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 163522375 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500687694 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100257570 . This is a "KENTUCKY (P), PASSPORT HEALTH PLAN, WELLCARE OF KENTUCKY" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100264920-00 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103011190-0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1508146010 . This is a "FLORIDA CHILDREN'S MEDICAL SERVICES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 1508146010 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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