Healthcare Provider Details

I. General information

NPI: 1386678142
Provider Name (Legal Business Name): KROGER CO OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W ARGYLE ST
JACKSON MI
49202-2059
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-5476
  • Fax: 517-788-9666
Mailing address:
  • Phone: 513-762-1019
  • Fax: 513-762-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5301003996
License Number StateMI

VIII. Authorized Official

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