Provider Demographics
NPI:1326072125
Name:KROGER LIMITED PARTNERSHIP I
Entity Type:Organization
Organization Name:KROGER LIMITED PARTNERSHIP I
Other - Org Name:KROGER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MERCHANDISER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCCINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-782-3384
Mailing Address - Street 1:150 TRI COUNTY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3217
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 N GETTYSBURG AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-1564
Practice Address - Country:US
Practice Address - Phone:937-268-0128
Practice Address - Fax:937-268-7364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
OH333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3648738OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OH0671938Medicaid