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	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	60005712	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	2024601	OTHER		PK

General Provider Information

NPI Number	:	1174696694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER LIMITED PARTNERSHIP I

Provider Business Mailing Address
First Line	:	5173 W WASHINGTON ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-2205
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	5173 W WASHINGTON ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46241-2205
Country	:	US
Telephone Number	:	317-381-9659
Fax Number	:	317-381-9678

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON MUENNICH
Credential	:
Telephone Number	:	513-762-1019

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	06/13/2016

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