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	5301007646	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2046199	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942234711
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	:	513-762-1090
Fax Number	:

Provider Business Practice Location Address
First Line	:	45540 MICHIGAN AVE
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2472
Country	:	US
Telephone Number	:	734-397-2560
Fax Number	:	734-397-2691

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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