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	PHY01592	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2904399	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1114095015
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALPHS GROCERY COMPANY

Provider Business Mailing Address
First Line	:	1100 W ARTESIA BLVD
Second Line	:
City	:	COMPTON
State	:	CA
Zip	:	90220-5108
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2255 N LAS VEGAS BLVD
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89030-5840
Country	:	US
Telephone Number	:	702-642-1111
Fax Number	:	702-642-4959

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	:	02/04/2009

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Directions to “RALPHS GROCERY COMPANY ” Practice Location

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