NPIMap

Organization Active NPI

Kroger Limited Partnership I

Doing business as Kroger Pharmacy

  • Community/Retail Pharmacy
  • Vicksburg, MS
National Provider Identifier
1093749871
Registry record updated Jun 24, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
1957012 Issued in MS
Legal business name
KROGER LIMITED PARTNERSHIP I
Doing business as
Kroger Pharmacy
Practice address
3405 Pemberton Square Blvd
Vicksburg, MS 39180-5574
Phone
(601) 638-3412
Fax
(601) 638-3628
NPI assigned
Jul 10, 2006
Last updated
Jun 24, 2009By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 24, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Matt Mineer
Title
Interface Manager
Phone
(513) 387-7074

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 1957012 MS Primary

Addresses

Primary practice location

3405 Pemberton Square Blvd
Vicksburg, MS 39180-5574

Mailing address

800 Ridge Lake Blvd
Memphis, TN 38120-9427
Phone (901) 765-4157

Other identifiers 2

IdentifierTypeStateIssuer
0330556MedicaidMS
2514873OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names 1

  • KROGER PHARMACY Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080221000144 MS Part B Supplier - Mass Immunization (Roster Biller Only) 8224930136 30 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Laurel, MS; Jackson, MS; Madison, MS; Olive Branch, MS; Oxford, MS; Richland, MS; Ridgeland, MS; Southaven, MS…

Other NPIs on the same Medicare enrollment 30

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 30

National Provider Directory

National Provider Directory
Tax ID family
Kroger Pharmacy 29209611 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 14

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152489600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1245801600000",
    "number": "1093749871",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 RIDGE LAKE BLVD",
            "city": "MEMPHIS",
            "state": "TN",
            "postal_code": "381209427",
            "telephone_number": "901-765-4157",
            "fax_number": "901-765-4213"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3405 PEMBERTON SQUARE BLVD",
            "city": "VICKSBURG",
            "state": "MS",
            "postal_code": "391805574",
            "telephone_number": "601-638-3412",
            "fax_number": "601-638-3628"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KROGER LIMITED PARTNERSHIP I",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-10",
        "last_updated": "2009-06-24",
        "status": "A",
        "authorized_official_last_name": "MINEER",
        "authorized_official_first_name": "MATT",
        "authorized_official_title_or_position": "INTERFACE MANAGER",
        "authorized_official_telephone_number": "513-387-7074"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MS",
            "license": "1957012",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0330556",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "2514873",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KROGER PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Vicksburg, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.