Provider Demographics
NPI:1659607141
Name:KROGER LIMITED PARTNERSHIP I
Entity Type:Organization
Organization Name:KROGER LIMITED PARTNERSHIP I
Other - Org Name:KROGER PHARMACY #698
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SEILHAMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-762-1090
Mailing Address - Street 1:PO BOX 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:5201 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37918-2345
Practice Address - Country:US
Practice Address - Phone:865-686-1020
Practice Address - Fax:865-656-1021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TN00000046803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519814Medicaid
2122366OtherPK
2122366OtherPK
P00003796Medicare PIN
103G736597Medicare PIN