Healthcare Provider Details

I. General information

NPI: 1245415868
Provider Name (Legal Business Name): KROGER LIMITED PARTNERSHIP I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 COLONY CROSSING WAY
MADISON MS
39110-7697
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 601-605-5024
  • Fax: 601-605-5027
Mailing address:
  • Phone: 513-762-1019
  • Fax: 513-762-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0765011
License Number StateMS

VIII. Authorized Official

Name: JESSIE WARMAN
Title or Position: MANAGER OF PHARMACY LICENSING
Credential:
Phone: 513-762-1090