1013913458 NPI number — KROGER SPECIALTY PHARMACY CA, LLC

Table of content: (NPI 1013913458)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013913458 NPI number — KROGER SPECIALTY PHARMACY CA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KROGER SPECIALTY PHARMACY CA, 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:
Provider Other Organization Name Type Code:
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:
1013913458
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7373 LINCOLN WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-622-6700
Provider Business Mailing Address Fax Number:
866-539-1092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7373 LINCOLN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92841-1428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-622-6700
Provider Business Practice Location Address Fax Number:
866-539-1092
Provider Enumeration Date:
06/21/2005

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: 332BP3500X ; 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 , with the licence number: PHY54648 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24079073 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013913458 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 35356383 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500739393 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 825265 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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