Healthcare Provider Details

I. General information

NPI: 1659444263
Provider Name (Legal Business Name): KROGER TEXAS L P
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 E HIGHWAY 377
GRANBURY TX
76048-2646
US

IV. Provider business mailing address

19245 DAVID MEMORIAL DR
SHENANDOAH TX
77385-8778
US

V. Phone/Fax

Practice location:
  • Phone: 817-573-3745
  • Fax: 817-573-7515
Mailing address:
  • Phone: 713-507-6276
  • Fax: 936-442-6704

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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20215
License Number StateTX

VIII. Authorized Official

Name: KARLA LANGWORTHY
Title or Position: MANAGER OF PHARMACY CREDENTIALING
Credential:
Phone: 513-698-1878