NPIMap

Organization Active NPI

Kroger Co of Michigan

  • Community/Retail Pharmacy
  • St. Clair Shores, MI
National Provider Identifier
1154521060
Registry record updated Jun 14, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
5301008647 Issued in MI
Legal business name
KROGER CO OF MICHIGAN
Practice address
22801 Harper Ave
St. Clair Shores, MI 48080
Phone
(586) 800-5190
Fax
(586) 800-5195
NPI assigned
Jul 19, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 14, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bill Shinton
Title
Vice President Kroger Health
Phone
(513) 762-1090

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X
Community/Retail Pharmacy 3336C0003X 5301008647 MI Primary

Addresses

Primary practice location

22801 Harper Ave
St. Clair Shores, MI 48080

Mailing address

PO Box 842772
Boston, MA 02284-2772
Phone (513) 762-1019

Other identifiers 2

IdentifierTypeStateIssuer
2369975MedicaidMI
2042697OtherPK

Other names 1

  • Kroger Pharmacy #749 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20041110000810 MI Part B Supplier - Mass Immunization (Roster Biller Only) 8820051816 This NPI is an additional NPI on the enrollment
O20100930099518 MI DME Supplier - PharmacyDME Supplier - Grocery Store 8820051816 Practice locations: Saint Clair Shores, MI

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D2077075Kroger Co of Michigan #018-749, the22801 Harper Ave, Saint Clair Shores, MI 48080Certificate of waiverApr 29, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Kroger Co of Michigan22801 Harper Ave, Saint Clair Shores, MI 48080-1848(586) 800-5190 Immunosuppressive Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Commodes, Urinals, Bedpans|Blood Glucose Monitors/Supplies (Non-Mail Order)|Canes and/or Crutches|Walkers|Ostomy Supplies|Urological Supplies|Enteral Nutrients|Enteral Equipment and/or Supplies|Nebulizer Equipment a… Accepts assignmentParticipating since Nov 5, 2020

National Provider Directory

National Provider Directory
Tax ID family
Kroger Co of Michigan106 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1184803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623628800000",
    "number": "1154521060",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 842772",
            "city": "BOSTON",
            "state": "MA",
            "postal_code": "022842772",
            "telephone_number": "513-762-1019",
            "fax_number": "513-762-1092"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "22801 HARPER AVE",
            "city": "ST. CLAIR SHORES",
            "state": "MI",
            "postal_code": "48080",
            "telephone_number": "586-800-5190",
            "fax_number": "586-800-5195"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KROGER CO OF MICHIGAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-19",
        "last_updated": "2021-06-14",
        "certification_date": "2021-06-14",
        "status": "A",
        "authorized_official_last_name": "SHINTON",
        "authorized_official_first_name": "BILL",
        "authorized_official_title_or_position": "VICE PRESIDENT KROGER HEALTH",
        "authorized_official_telephone_number": "513-762-1090"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MI",
            "license": "5301008647",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2369975",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2042697",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Kroger Pharmacy #749",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in St. Clair Shores, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 14, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.