Kroger Co of Michigan
Organization Active NPI Community/Retail Pharmacy · Essexville, MI
NPI 1295769032 · NPPES record last updated Jan 16, 2019
Key facts
- NPI
- 1295769032
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 5301006157 (MI)
- Legal business name
- KROGER CO OF MICHIGAN
- Practice address
- 2910 Center Ave
Essexville, MI 48732-1704 - Phone
- (989) 892-0313
- Fax
- (989) 892-9675
- NPI assigned
- Jul 10, 2006
- Organization subpart
- No
Authorized official
- Name
- Jessie Warman
- Title
- Manager RX Licensing
- Phone
- (513) 762-1090
Corporate family (same tax ID) 24
Member of 1
Practitioners 5
-
Charles Vana, PHARMD
-
Brandon Wyman, PHARM.D.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 23D2076874 | The Kroger Co of Michigan | Certificate of waiver | Apr 28, 2028 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Kroger Co of Michigan |
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 assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MI
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20041110000810 | MI | Part B Supplier - Mass Immunization (Roster Biller Only) | 8820051816 | This NPI is an additional NPI on the enrollment |
| O20100930011421 | MI | DME Supplier - Pharmacy |
8820051816 | Practice locations: Essexville, MI |
National Provider Directory
- Tax ID family
- Kroger Co of Michigan
Locations
2910 Center Ave
Essexville, MI 48732
Phone (989) 892-0313
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 5301006157 | MI | Yes |
Addresses
Primary practice location
2910 Center Ave
Essexville, MI 48732-1704
Mailing address
PO Box 842772
Boston, MA 02284-2772
Phone (513) 762-1090
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2042566 | Other | PK | |
| 3092795 | Medicaid | MI |
Other names
- KROGER PHARMACY
Other providers in Essexville, MI
- Evan Koehn
- Melissa Kohner
- Ekaterini Kostakos
- Olga Kostakos
- Bethany Kozielski
- Alivia Jo Kukla
- Shaina Linn Lacasse
- Terrance Lafond Jr.
- Lakeshore Diagnostics Ultrasound Co.
- Lakeshore Diagnostics Ultrasound, Co.
All providers in Essexville, MI · Community/Retail Pharmacy in Michigan
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 16, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.