Provider Demographics
NPI:1245264050
Name:THE KROGER CO
Entity type:Organization
Organization Name:THE KROGER CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF PHARMACY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-8725
Mailing Address - Street 1:PO BOX 830242
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0242
Mailing Address - Country:US
Mailing Address - Phone:513-387-8725
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:7380 SPOUT SPRINGS RD
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-7541
Practice Address - Country:US
Practice Address - Phone:770-965-5644
Practice Address - Fax:770-965-5632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
GA87343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA253387914BMedicaid
2015407OtherPK
2015407OtherPK
GA253387914BMedicaid
P00003265Medicare PIN