=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841363157
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KROGER LIMITED PARTNERSHIP I
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 10/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 537 S REED RD
-----------------------------------------------------
City | KOKOMO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46901-5692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-454-5289
-----------------------------------------------------
Fax | 765-454-5296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 VINE ST
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45202-1141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR PHARMACY INTERFACE
-----------------------------------------------------
Name | MATTHEW FELTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-762-1095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 60005159
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------