=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144254905
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KROGER CO OF MICHIGAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2006
-----------------------------------------------------
Last Update Date | 01/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 HAGGERTY RD
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48323-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-960-7535
-----------------------------------------------------
Fax | 248-960-7529
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40399 GRAND RIVER AVE STE 110
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48375-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-536-1545
-----------------------------------------------------
Fax | 248-536-1599
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER RX LICENSING
-----------------------------------------------------
Name | JESSIE WARMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-762-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 5301006519
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------