MEDICARE: KROGER TEXAS LIMITED PARTNERSHIP

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	20203	TX

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	4564262	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1639242167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER TEXAS LIMITED PARTNERSHIP

Provider Business Mailing Address
First Line	:	19245 DAVID MEMORIAL DR
Second Line	:
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8778
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	295 SAWDUST RD
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77380-2238
Country	:	US
Telephone Number	:	281-363-3595
Fax Number	:	281-363-2405

Authorized Official
Title or Position	:	PHARMACY ECOMMERCE MANAGER
Name	:	ANGELA TRUSTER
Credential	:
Telephone Number	:	513-387-7113

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	02/20/2009

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Directions to “KROGER TEXAS LIMITED PARTNERSHIP ” Practice Location

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