Healthcare Provider Details

I. General information

NPI: 1144254905
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

4805 HAGGERTY RD
WEST BLOOMFIELD MI
48323-3901
US

IV. Provider business mailing address

40399 GRAND RIVER AVE STE 110
NOVI MI
48375-2148
US

V. Phone/Fax

Practice location:
  • Phone: 248-960-7535
  • Fax: 248-960-7529
Mailing address:
  • Phone: 248-536-1545
  • Fax: 248-536-1599

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 Number5301006519
License Number StateMI

VIII. Authorized Official

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