Provider Demographics
NPI:1639103401
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:INTERFACE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:800 RIDGE LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9427
Mailing Address - Country:US
Mailing Address - Phone:901-765-4157
Mailing Address - Fax:901-765-4213
Practice Address - Street 1:406 SPRINGRIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4804
Practice Address - Country:US
Practice Address - Phone:601-924-7422
Practice Address - Fax:601-924-7423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MS15590123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2512502OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS0330553Medicaid
1193770154Medicare NSC
2512502OtherNCPDP PROVIDER IDENTIFICATION NUMBER