Healthcare Provider Details

I. General information

NPI: 1750837670
Provider Name (Legal Business Name): KROGER CO OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 01/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 E 12 MILE RD
ROYAL OAK MI
48067-1504
US

IV. Provider business mailing address

PO BOX 842772
BOSTON MA
02284-2772
US

V. Phone/Fax

Practice location:
  • Phone: 248-397-1530
  • Fax: 248-397-1532
Mailing address:
  • Phone: 513-762-1019
  • Fax:

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 Number5301011042
License Number StateMI

VIII. Authorized Official

Name: ALLISON BREDESTEGE
Title or Position: MANAGER OF PHARMACY LICENSING
Credential:
Phone: 513-762-1263