NPIMap

Organization Active NPI

The Kroger Co

  • Community/Retail Pharmacy
  • Rincon, GA
National Provider Identifier
1306202890
Registry record updated Jul 20, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
Legal business name
THE KROGER CO
Practice address
461 S Columbia Ave
Rincon, GA 31326
Phone
(912) 826-7665
Fax
(912) 826-7667
NPI assigned
Jan 13, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 20, 2018

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)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X Primary

Addresses

Primary practice location

461 S Columbia Ave
Rincon, GA 31326

Mailing address

PO Box 842772
Boston, MA 02284-2772
Phone (513) 762-1019

Other identifiers 2

IdentifierTypeStateIssuer
2157520OtherPK
003175280AMedicaidGA

Other names 1

  • Kroger Pharmacy #625 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20090227000285 GA Part B Supplier - Mass Immunization (Roster Biller Only) 6103738653 This NPI is an additional NPI on the enrollment
O20160630002482 GA DME Supplier - Pharmacy 6103738653 Practice locations: Rincon, GA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2129427Kroger Pharmacy # 625461 S Columbia Avenue, Rincon, GA 31326Certificate of waiverApr 18, 2027

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
The Kroger Co461 S Columbia Ave, Rincon, GA 31326-9446(912) 826-7665 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 assignmentParticipating since Oct 18, 2023

National Provider Directory

National Provider Directory
Tax ID family
Kroger Sav on J926319 organizations share this tax ID, including this one

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.

View all 24

Locations

461 S Columbia Ave
Rincon, GA 31326
Phone (912) 584-7140

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1452643200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1532044800000",
    "number": "1306202890",
    "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": "461 S COLUMBIA AVE",
            "city": "RINCON",
            "state": "GA",
            "postal_code": "31326",
            "telephone_number": "912-826-7665",
            "fax_number": "912-826-7667"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE KROGER CO",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-13",
        "last_updated": "2018-07-20",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2157520",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003175280A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kroger Pharmacy #625",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Kroger Pharmacy #625",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Rincon, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 20, 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.

Verify at the official NPI Registry.