Provider Demographics
NPI:1457551384
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 842772
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-2772
Mailing Address - Country:US
Mailing Address - Phone:513-762-1019
Mailing Address - Fax:513-762-1092
Practice Address - Street 1:64660 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2853
Practice Address - Country:US
Practice Address - Phone:586-540-8004
Practice Address - Fax:586-540-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010086573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2042696OtherPK
MI2369963Medicaid
2663030033Medicare NSC
0P02440Medicare PIN
P00246579Medicare PIN