Provider Demographics
NPI:1518982214
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:
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:150 TRI COUNTY PKWY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3217
Mailing Address - Country:US
Mailing Address - Phone:513-782-3384
Mailing Address - Fax:513-782-8760
Practice Address - Street 1:350 E SIX FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7879
Practice Address - Country:US
Practice Address - Phone:919-835-9593
Practice Address - Fax:919-835-9837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
NC74893336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3437337OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NC0920118Medicaid