1063695187 NPI number — KROGER LIMITED PARTNERSHIP I

Table of content: (NPI 1063695187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063695187 NPI number — KROGER LIMITED PARTNERSHIP I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KROGER LIMITED PARTNERSHIP I
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KROGER APOTHECARY MIDATLANTIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063695187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
621 TOWNSIDE RD SW STE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24014-2297
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-345-6480
Provider Business Mailing Address Fax Number:
540-345-6844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621-F TOWNSHIP PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-345-6480
Provider Business Practice Location Address Fax Number:
540-345-6844
Provider Enumeration Date:
12/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
JEFF
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MERCHANDISER
Authorized Official Telephone Number:
540-563-3593

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0201003731 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201003731 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4836055 . This is a "NCPDP" identifier . This identifiers is of the category "OTHER".




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