Provider Demographics
NPI:1699709485
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:PHARMACY LICENSING MANAGER
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 1:3631 PETERS CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2809
Mailing Address - Country:US
Mailing Address - Phone:540-563-3593
Mailing Address - Fax:540-563-1436
Practice Address - Street 1:3032 E CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4858
Practice Address - Country:US
Practice Address - Phone:304-327-0823
Practice Address - Fax:304-327-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
WV5522433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0013178037Medicaid
5011440OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA008517592Medicaid
VA008517592Medicaid
WV0013178037Medicaid