MEDICARE: KROGER TEXAS L P

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	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	20131	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2096705	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508939828
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER TEXAS L P

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	9114 CAMP BOWIE WEST BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6023
Country	:	US
Telephone Number	:	817-560-4233
Fax Number	:	817-244-8964

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

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	05/16/2016

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Directions to “KROGER TEXAS L P ” Practice Location

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