MEDICARE: KROGER CO OF MICHIGAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	5301005679	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2041356	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306870142
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER CO OF MICHIGAN

Provider Business Mailing Address
First Line	:	PO BOX 842772
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02284-2772
Country	:	US
Telephone Number	:	513-762-1019
Fax Number	:	513-762-1092

Provider Business Practice Location Address
First Line	:	108 W HIGHLAND RD
Second Line	:
City	:	HOWELL
State	:	MI
Zip	:	48843-1159
Country	:	US
Telephone Number	:	517-552-0205
Fax Number	:	517-552-0325

Authorized Official
Title or Position	:	MANAGER RX LICENSING
Name	:	JESSIE WARMAN
Credential	:
Telephone Number	:	513-762-1090

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	01/25/2019

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Directions to “KROGER CO OF MICHIGAN ” Practice Location

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