Healthcare Provider Details

I. General information

NPI: 1609076520
Provider Name (Legal Business Name): KROGER CO OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20422 MACK AVE
GROSSE POINTE MI
48236-1676
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 313-308-1033
  • Fax: 313-308-1036
Mailing address:
  • Phone: 513-762-1090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301008652
License Number StateMI

VIII. Authorized Official

Name: JESSIE WARMAN
Title or Position: MANAGER RX LICENSING
Credential:
Phone: 513-762-1090