Provider Demographics
NPI:1720012586
Name:KROGER CO OF MICHIGAN
Entity Type:Organization
Organization Name:KROGER CO OF MICHIGAN
Other - Org Name:KROGER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER RX LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-762-1090
Mailing Address - Street 1:PO BOX 842787
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3430 STATE ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3354
Practice Address - Country:US
Practice Address - Phone:989-793-3456
Practice Address - Fax:989-793-2396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-01-25
Deactivation Date:2009-01-13
Deactivation Code:
Reactivation Date:2009-07-28
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010071253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2344389OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MI4161995Medicaid
2344389OtherNCPDP PROVIDER IDENTIFICATION NUMBER