Provider Demographics
NPI:1073686697
Name:KROGER TEXAS L P
Entity Type:Organization
Organization Name:KROGER TEXAS L P
Other - Org Name:KROGER PHARMACY #150
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUENNICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:PO BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:6315 GARTH RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-9686
Practice Address - Country:US
Practice Address - Phone:346-216-4155
Practice Address - Fax:346-216-4157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX201913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464538Medicaid
2105423OtherPK
P00170633Medicare PIN
TX464538Medicaid
PH0431Medicare PIN