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	5301007043	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2044503	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912931767
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KROGER CO OF MICHIGAN

Provider Business Mailing Address
First Line	:	40399 GRAND RIVER AVE STE 110
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48375-2148
Country	:	US
Telephone Number	:	248-536-1545
Fax Number	:	248-536-1599

Provider Business Practice Location Address
First Line	:	15251 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48042-4056
Country	:	US
Telephone Number	:	586-677-0968
Fax Number	:	810-677-9794

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	:	01/16/2019

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Directions to “KROGER CO OF MICHIGAN ” Practice Location

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