Active NPI
Kroger Texas L P
Doing business as Kroger Pharmacy
- Community/Retail Pharmacy
- Mesquite, TX
National Provider Identifier
1184797615
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- 20134
- Legal business name
- KROGER TEXAS L P
- Doing business as
- Kroger Pharmacy
- Practice address
- 3600 Gus Thomasson Rd
Mesquite, TX 75150-6200 - Phone
- (972) 270-2401
- Fax
- (972) 613-2465
- NPI assigned
- Nov 15, 2006
- Last updated
- Oct 26, 2018
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Jessie Warman
- Title
- Manager of Pharmacy Licensing
- Phone
- (513) 762-1019
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 20134 | TX | Primary |
Addresses
Primary practice location
3600 Gus Thomasson Rd
Mesquite, TX 75150-6200
Mailing address
PO Box 842772
Boston, MA 02284-2772
Phone (513) 762-1019
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 464607 | Medicaid | TX | |
| 2103632 | Other | PK |
Other names 1
- KROGER PHARMACY
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041103001304 | TX | Part B Supplier - Mass Immunization (Roster Biller Only) | 9638131303 | This NPI is an additional NPI on the enrollment |
| O20100930059988 | TX | DME Supplier - Pharmacy | 9638131303 | Practice locations: Mesquite, TX |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 45D2001585 | Kroger Pharmacy 450 | Certificate of waiver | Dec 21, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Kroger Pharmacy #450 | Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Commodes, Urinals, Bedpans|Blood Glucose Monitors/Supplies (Non-Mail Order)|Canes and/or Crutches|Walkers|Ostomy Supplies|Urological Supplies|Enteral Nutrients|Enteral Equipment and/or Supplies|Nebulizer Equipment a… | Accepts assignment |
National Provider Directory
National Provider Directory- Tax ID family
- Kroger Texas
Organizations with this tax ID in the same state 24
This tax ID family is large, so up to 24 of its organizations in the same state are linked here.
Member of 1
Organizations this organization is a member of, according to the National Provider Directory.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1163548800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1540512000000",
"number": "1184797615",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 842772",
"city": "BOSTON",
"state": "MA",
"postal_code": "022842772",
"telephone_number": "513-762-1019",
"fax_number": "513-762-1092"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3600 GUS THOMASSON RD",
"city": "MESQUITE",
"state": "TX",
"postal_code": "751506200",
"telephone_number": "972-270-2401",
"fax_number": "972-613-2465"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "KROGER TEXAS L P",
"organizational_subpart": "NO",
"enumeration_date": "2006-11-15",
"last_updated": "2018-10-26",
"status": "A",
"authorized_official_last_name": "WARMAN",
"authorized_official_first_name": "JESSIE",
"authorized_official_title_or_position": "MANAGER OF PHARMACY LICENSING",
"authorized_official_telephone_number": "513-762-1019"
},
"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": "TX",
"license": "20134",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "464607",
"state": "TX"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2103632",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "KROGER PHARMACY",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "KROGER PHARMACY",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Mesquite, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 26, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.