Provider Demographics
NPI:1134153901
Name:KROGER LIMITED PARTNERSHIP I
Entity type:Organization
Organization Name:KROGER LIMITED PARTNERSHIP I
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INTERFACE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:MINEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-387-7074
Mailing Address - Street 1:3631 PETERS CREEK RD NW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-2809
Mailing Address - Country:US
Mailing Address - Phone:540-563-3593
Mailing Address - Fax:540-265-1211
Practice Address - Street 1:14346 WARWICK BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-3814
Practice Address - Country:US
Practice Address - Phone:757-877-7963
Practice Address - Fax:757-877-0663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
VA02010034153336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008508631Medicaid
4835596OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4835596OtherNCPDP PROVIDER IDENTIFICATION NUMBER
VA008508631Medicaid