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	3336C0003X	Community/Retail Pharmacy	60006088A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1561578	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1053516880
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	:	5725 COVENTRY LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7146
Country	:	US
Telephone Number	:	260-434-0497
Fax Number	:	260-434-0518

Authorized Official
Title or Position	:	PHARMACY LICENSING MANAGER
Name	:	KARLA LANGWORTHY
Credential	:	CPHT
Telephone Number	:	513-698-1878

Provider Enumeration Date	:	06/20/2007
Last Update Date	:	03/03/2011

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