MEDICARE: KROGER CO

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	7474	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2167707	OTHER		PK

General Provider Information

NPI Number	:	1932647179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER CO

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	:

Provider Business Practice Location Address
First Line	:	2010 COUNTRY CLUB RD
Second Line	:
City	:	LAKE CHARLES
State	:	LA
Zip	:	70605-5206
Country	:	US
Telephone Number	:	337-990-4902
Fax Number	:	337-990-4904

Authorized Official
Title or Position	:	MANAGER OF PHARMACY LICENSING
Name	:	ALLISON BREDESTEGE
Credential	:
Telephone Number	:	513-762-1263

Provider Enumeration Date	:	02/08/2017
Last Update Date	:	03/15/2018

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Directions to “KROGER CO ” Practice Location

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