1063446870 NPI number — THE KROGER CO

Table of content: (NPI 1063446870)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063446870 NPI number — THE KROGER CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE KROGER CO
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:
Provider Other Organization Name Type Code:
6
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:
1063446870
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 842772
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02284-2772
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-762-1019
Provider Business Mailing Address Fax Number:
513-762-1092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4815 RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOUGLASVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30134-6142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-949-2661
Provider Business Practice Location Address Fax Number:
770-949-2894
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MUENNICH
Authorized Official First Name:
ALLISON
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER OF PHARMACY LICENSING
Authorized Official Telephone Number:
513-762-1019

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 8813 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2015552 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 291870832A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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