Provider Demographics
NPI:1629321823
Name:KROGER CO
Entity Type:Organization
Organization Name:KROGER CO
Other - Org Name:KROGER PHARMACY #619
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:P.O. BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:1524 GEORGIA HIGHWAY 16 W
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-2046
Practice Address - Country:US
Practice Address - Phone:770-229-7430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137594OtherPK
GA003129888AMedicaid
0302061056Medicare NSC
GA003129888AMedicaid