NPIMap

Organization Active NPI

The Kroger Co

Doing business as Kroger Pharmacy #644

  • Community/Retail Pharmacy
  • Grovetown, GA
National Provider Identifier
1710335443
Registry record updated Jul 20, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHRE010302 Issued in GA
Legal business name
THE KROGER CO
Doing business as
Kroger Pharmacy #644
Practice address
435 Lewiston Rd
Grovetown, GA 30813
Phone
(770) 496-5332
NPI assigned
Jun 3, 2016
Last updated
Jul 20, 2018By the provider in NPPES
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) 762-1263

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X NU
Community/Retail Pharmacy 3336C0003X PHRE010302 GA Primary

Addresses

Primary practice location

435 Lewiston Rd
Grovetown, GA 30813

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
2160509OtherPK

Other names 1

  • KROGER PHARMACY #644 Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20150727002118 GA Part B Supplier - Mass Immunization (Roster Biller Only) 6103738653 5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Atlanta, GA; Augusta, GA; Cumming, GA; Grovetown, GA; Savannah, GA
O20161116003044 GA DME Supplier - Pharmacy 6103738653 Practice locations: Grovetown, GA

Other NPIs on the same Medicare enrollment 5

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

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
11D2118753Kroger Pharmacy #644435 Lewiston Road, Grovetown, GA 30813Certificate of waiverSep 13, 2026

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
The Kroger Co435 Lewiston Rd, Grovetown, GA 30813-4221(706) 619-3430 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 Pharmacy 957319 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

435 Lewiston Rd
Grovetown, GA 30813
Phone (706) 619-3430

NPI Registry JSON

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

{
    "created_epoch": "1464912000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1532044800000",
    "number": "1710335443",
    "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"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "435 LEWISTON RD",
            "city": "GROVETOWN",
            "state": "GA",
            "postal_code": "30813",
            "telephone_number": "770-496-5332"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE KROGER CO",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-03",
        "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": "513-762-1263"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "GA",
            "license": "PHRE010302",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2160509",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KROGER PHARMACY #644",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "KROGER PHARMACY #644",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Grovetown, 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.