Kroger Limited Partnership I

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

60006074A Issued in IN

Legal business name

KROGER LIMITED PARTNERSHIP I

Doing business as

Scotts Pharmacy J417

Practice address

1801 N Wayne St
Angola, IN 46703-2360

Phone

(260) 624-3110

Fax

(260) 624-3920

NPI assigned

Jun 11, 2007

Organization subpart

No

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

Authorized official

Name

Matt Mineer, CPHT

Title

Interface Manager

Phone

(513) 387-7074

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• SCOTTS PHARMACY J417 Doing business as

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

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

{
    "created_epoch": "1181520000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1245801600000",
    "number": "1831393354",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5960 CASTLEWAY WEST DR",
            "city": "INDIANAPOLIS",
            "state": "IN",
            "postal_code": "462501977",
            "telephone_number": "317-579-8434",
            "fax_number": "317-579-8424"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1801 N WAYNE ST",
            "city": "ANGOLA",
            "state": "IN",
            "postal_code": "467032360",
            "telephone_number": "260-624-3110",
            "fax_number": "260-624-3920"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KROGER LIMITED PARTNERSHIP I",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-06-11",
        "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",
        "authorized_official_credential": "CPHT"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "IN",
            "license": "60006074A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200866230A",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "1561530",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SCOTTS PHARMACY J417",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Lon Nicholas Keyes, R.PH.
• Janice A. King, LMHC, LMFT
• Brittany S Knox, FNP-BC
• Alexandra Marie Konyndyk
• Karissa R Kreider, FNP
• Alison R. Kwolek, MSED
• Shelley Carroll Lafferty, MSW, LCSW
• Lauren A Laroe, PMHNP
• Audra Lehman, FNP-C
• James Edward Leslie, PT

• Community/Retail Pharmacy in Angola, IN
• Providers in Angola, IN by specialty
• Community/Retail Pharmacy in Indiana

• 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.