=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639103401
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KROGER LIMITED PARTNERSHIP I
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 06/24/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 406 SPRINGRIDGE RD
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-4804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-924-7422
-----------------------------------------------------
Fax | 601-924-7423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 RIDGE LAKE BLVD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-9427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-765-4157
-----------------------------------------------------
Fax | 901-765-4213
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERFACE MANAGER
-----------------------------------------------------
Name | MATT MINEER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-387-7074
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1559012
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------