Organization
KROGER LIMITED PARTNERSHIP I
Active
Other names
KROGER PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
MATT MINEER (INTERFACE MANAGER)
(513) 387-7074
Entity
Organization
Contact information
Practice address
3405 PEMBERTON SQUARE BLVD, VICKSBURG, MS 39180-5574
(601) 638-3412
(601) 638-3628
Mailing address
800 RIDGE LAKE BLVD, MEMPHIS, TN 38120-9427
(901) 765-4157
(901) 765-4213
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
1957012
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0330556
—
MS
01
—
2514873
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
07/10/2006
Last updated
06/24/2009
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