Provider Demographics
NPI:1912931767
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 1:40399 GRAND RIVER AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-2148
Mailing Address - Country:US
Mailing Address - Phone:248-536-1545
Mailing Address - Fax:248-536-1599
Practice Address - Street 1:15251 23 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4056
Practice Address - Country:US
Practice Address - Phone:586-677-0968
Practice Address - Fax:810-677-9794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MI53010070433336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2044503OtherPK
MI4119196Medicaid
MI4119196Medicaid
2044503OtherPK
2663030072Medicare NSC