Provider Demographics
NPI:1376616805
Name:KROGER TEXAS L P
Entity Type:Organization
Organization Name:KROGER TEXAS L P
Other - Org Name:KROGER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1019
Mailing Address - Street 1:19245 DAVID MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-8778
Mailing Address - Country:US
Mailing Address - Phone:713-507-6276
Mailing Address - Fax:936-442-6704
Practice Address - Street 1:1461 SPRING CYPRESS RD
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77373-2544
Practice Address - Country:US
Practice Address - Phone:281-353-8204
Practice Address - Fax:281-353-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX201753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX464517Medicaid
2103167OtherPK
PH0431Medicare PIN
1307140098Medicare NSC
TX464517Medicaid