Basic Information
| Provider Information | |||||||||
| NPI: | 1861897738 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KROGER CO. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2858 N PINAL AVE | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851227917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204264701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2858 N PINAL AVE | ||||||||
| Address2: | |||||||||
| City: | CASA GRANDE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851227917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204264701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | LE | ||||||||
| AuthorizedOfficialFirstName: | LOC | ||||||||
| AuthorizedOfficialMiddleName: | KHAC | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5204264701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | S012817 | AZ | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.