MEDICARE: KROGER SPECIALTY PHARMACY FL 2 LLC

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy
4	3336S0011X	Specialty Pharmacy	PH25629	FL

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	201116160B	OTHER	KS	KANSAS (P) (CHILDREN WITH SPECIAL HEALTHCARE NEEDS)
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
12	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
13	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
14	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
15	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
16	7100257570	OTHER	KY	KENTUCKY (P), PASSPORT HEALTH PLAN, WELLCARE OF KENTUCKY
17	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
18	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
19	1508146010	OTHER	FL	FLORIDA CHILDREN'S MEDICAL SERVICES
20	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
21	18-20-CC-9559	OTHER	KY	KENTUCKY (CHILDREN WITH SPECIAL HEALTH CARE NEEDS)
22	200590550A	OTHER	OK	OKLAHOMA (P) CHILDREN WITH SPECIAL HEALTHCARE NEEDS PROGRAM VENDOR
23	201116160A	OTHER	KS	KANSAS (QMB)
24	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
25	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
26	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
27	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
28	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
29	Q036221	OTHER	ID	IDAHO (P) (CHILDREN WITH SPECIAL HEALTHCARE NEEDS)
30	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
31	1508146010	OTHER	IN	INDIANA CHILDREN'S SPECIAL HEALTH CARE SERVICES PROGRAM
32	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
33	2131644	OTHER		PK
34	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
35	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
36	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
37	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
38	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
39	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
40	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
41	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
42	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
43	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
44	15-17-CC-9559	OTHER	KY	KENTUCKY (CHILDREN WITH SPECIAL HEALTH CARE NEEDS)
45	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
46	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
47	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508146010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER SPECIALTY PHARMACY FL 2 LLC

Provider Business Mailing Address
First Line	:	6435 HAZELTINE NATIONAL DR STE 140
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-5156
Country	:	US
Telephone Number	:	855-274-1694
Fax Number	:	855-819-6922

Provider Business Practice Location Address
First Line	:	6435 HAZELTINE NATIONAL DR STE 140
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32822-5156
Country	:	US
Telephone Number	:	855-274-1694
Fax Number	:	855-819-6922

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DEBRA J COLE
Credential	:
Telephone Number	:	855-733-3126

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	09/30/2020

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