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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1487175493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER LIMITED PARTNERSHIP I

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4290 W JONATHAN MOORE PIKE
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-9585
Country	:	US
Telephone Number	:	812-267-5511
Fax Number	:

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

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	06/29/2017

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