Provider Demographics
NPI:1003840810
Name:THE KROGER CO
Entity Type:Organization
Organization Name:THE KROGER CO
Other - Org Name:KROGER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERFACE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:2175 PARKLAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2845
Mailing Address - Country:US
Mailing Address - Phone:770-496-5332
Mailing Address - Fax:770-496-7562
Practice Address - Street 1:9701 FORD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-6422
Practice Address - Country:US
Practice Address - Phone:912-756-2255
Practice Address - Fax:912-756-2607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
GA83303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00839583AMedicaid
1146516OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1146516OtherNCPDP PROVIDER IDENTIFICATION NUMBER
GA00839583AMedicaid
FLU346Medicare PIN