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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	60005167	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1520750	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497828016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER LIMITED PARTNERSHIP I

Provider Business Mailing Address
First Line	:	5960 CASTLEWAY WEST DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-1977
Country	:	US
Telephone Number	:	317-579-8434
Fax Number	:	317-579-8424

Provider Business Practice Location Address
First Line	:	5615 W 38TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46254-2921
Country	:	US
Telephone Number	:	317-299-6783
Fax Number	:	317-290-6404

Authorized Official
Title or Position	:	INTERFACE MANAGER
Name	:	MATT MINEER
Credential	:
Telephone Number	:	513-387-7074

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	06/24/2009

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