Provider Demographics
NPI:1053516880
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:PHARMACY LICENSING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGWORTHY
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:513-698-1878
Mailing Address - Street 1:5960 CASTLEWAY WEST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1977
Mailing Address - Country:US
Mailing Address - Phone:317-579-8434
Mailing Address - Fax:317-579-8424
Practice Address - Street 1:5725 COVENTRY LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7146
Practice Address - Country:US
Practice Address - Phone:260-434-0497
Practice Address - Fax:260-434-0518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60006088A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200872340AMedicaid
1561578OtherNCPDP PROVIDER IDENTIFICATION NUMBER
256660Medicare PIN
IN200872340AMedicaid
P00637372Medicare PIN