Provider Demographics
NPI:1366878134
Name:KROGER TEXAS LP
Entity type:Organization
Organization Name:KROGER TEXAS LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSING ASP
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-587-5303
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 1:500 MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-6740
Practice Address - Country:US
Practice Address - Phone:972-564-8490
Practice Address - Fax:972-564-8492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX288753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142258OtherPK
TX1307140246Medicaid
TX1307140246Medicaid
2142258OtherPK
P00170652Medicare PIN