Provider Demographics
NPI:1962608042
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 1:350 N GRANDSTAFF DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-1678
Practice Address - Country:US
Practice Address - Phone:260-357-4107
Practice Address - Fax:260-290-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1561592OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1193770076Medicare NSC
1561592OtherNCPDP PROVIDER IDENTIFICATION NUMBER
256660Medicare PIN