Provider Demographics
NPI:1215210786
Name:KROGER TEXAS L P
Entity Type:Organization
Organization Name:KROGER TEXAS L P
Other - Org Name:COUSHATTA FAMILY MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PHARMACY CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-698-1878
Mailing Address - Street 1:1014 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1141
Mailing Address - Country:US
Mailing Address - Phone:513-698-1878
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:287 PANTHER TRAIL DRIVE
Practice Address - Street 2:
Practice Address - City:KINDER
Practice Address - State:LA
Practice Address - Zip Code:70648
Practice Address - Country:US
Practice Address - Phone:337-738-3095
Practice Address - Fax:337-738-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-21
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0064313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2132006OtherPK
5DW08Medicare PIN
2132006OtherPK