Provider Demographics
NPI:1659576395
Name:KROGER LIMITED PARTNERSHIP I
Entity Type:Organization
Organization Name:KROGER LIMITED PARTNERSHIP I
Other - Org Name:SCOTTS PHARMACY J 404
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:CPHT
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:5960 CASTLEWAY WEST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1977
Mailing Address - Country:US
Mailing Address - Phone:317-579-8434
Mailing Address - Fax:317-579-8424
Practice Address - Street 1:5300 DECATUR RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46806-3058
Practice Address - Country:US
Practice Address - Phone:260-458-0840
Practice Address - Fax:260-458-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006086A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1561542OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN200872420AMedicaid
IN200872420AMedicaid
P00637372Medicare PIN
1193770678Medicare NSC