Provider Demographics
NPI:1831393354
Name:KROGER LIMITED PARTNERSHIP I
Entity type:Organization
Organization Name:KROGER LIMITED PARTNERSHIP I
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1801 N WAYNE ST
Practice Address - Street 2:
Practice Address - City:ANGOLA
Practice Address - State:IN
Practice Address - Zip Code:46703-2360
Practice Address - Country:US
Practice Address - Phone:260-624-3110
Practice Address - Fax:260-624-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006074A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200866230AMedicaid
1561530OtherNCPDP PROVIDER IDENTIFICATION NUMBER
IN200866230AMedicaid
1561530OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1193770682Medicare NSC