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	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	20314	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	4596144	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1982777504
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER TEXAS L P

Provider Business Mailing Address
First Line	:	19245 DAVID MEMORIAL DR
Second Line	:
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8778
Country	:	US
Telephone Number	:	713-507-6276
Fax Number	:	936-442-6704

Provider Business Practice Location Address
First Line	:	1050 BRIDGEWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0802
Country	:	US
Telephone Number	:	817-446-6673
Fax Number	:	817-446-4943

Authorized Official
Title or Position	:	PHARMACY LICENSING MANAGER
Name	:	KARLA LANGWORTHY
Credential	:
Telephone Number	:	513-698-1878

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	09/07/2010

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Directions to “KROGER TEXAS L P ” Practice Location

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