Provider Demographics
NPI:1659444263
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: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 1:19245 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 1:1420 E HIGHWAY 377
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-2646
Practice Address - Country:US
Practice Address - Phone:817-573-3745
Practice Address - Fax:817-573-7515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX202153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096801OtherPK
TX464617Medicaid
P00170652Medicare PIN
2096801OtherPK
1307140076Medicare NSC