MEDICARE: RALPHS GROCERY COMPANY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	PH01815	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2907028	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023186921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALPHS GROCERY COMPANY

Provider Business Mailing Address
First Line	:	3250 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7479
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 E FLAMINGO RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-7479
Country	:	US
Telephone Number	:	702-433-8375
Fax Number	:	702-433-8975

Authorized Official
Title or Position	:	PHARMACY ECOMMERCE MANAGER
Name	:	ANGELA TRUSTER
Credential	:
Telephone Number	:	513-387-7113

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	02/06/2009

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