MEDICARE: KROGER LIMITED PARTNERSHIP I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	54014125	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2024760	OTHER		PK

General Provider Information

NPI Number	:	1225062037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER LIMITED PARTNERSHIP I

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	501 N GIANT CITY RD
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62902-6417
Country	:	US
Telephone Number	:	618-549-9743
Fax Number	:	618-549-0683

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON MUENNICH
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	05/18/2016

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