NPIMap

Organization Active NPI

Kroger Co of Michigan

  • Community/Retail Pharmacy
  • Imlay City, MI
National Provider Identifier
1548460488
Registry record updated Jan 16, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
5301008654 Issued in MI
Legal business name
KROGER CO OF MICHIGAN
Practice address
1821 S Cedar St
Imlay City, MI 48444-1344
Phone
(810) 721-3262
Fax
(810) 721-3263
NPI assigned
Jul 19, 2007
Organization subpart
No

Authorized official

NPPES NPI Registry
Name
Jessie Warman
Title
Manager RX Licensing
Phone
(513) 762-1090

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

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

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
23D2077097Kroger Co of Michigan, the1821 S Cedar Street, Imlay City, MI 48444Certificate of waiverApr 29, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Kroger Co of Michigan1821S Cedar St, Imlay City, MI 48444-1344(810) 721-3262 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

Medicare participation

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

Medicare enrollment records 2

Medicare enrollment files
Enrollment IDStateProvider typePAC IDDetails
O20041110000810 MI Part B Supplier - Mass Immunization (Roster Biller Only) 8820051816 This NPI is an additional NPI on the enrollment
O20100930017397 MI DME Supplier - PharmacyDME Supplier - Grocery Store 8820051816 Practice locations: Imlay City, MI

National Provider Directory

National Provider Directory
Tax ID family
Kroger Co of Michigan (106 organizations share this tax ID)

Specialties & licenses 1

NPPES NPI Registry
Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 5301008654 MI Primary

Addresses

NPPES NPI Registry

Primary practice location

1821 S Cedar St
Imlay City, MI 48444-1344

Mailing address

PO Box 842772
Boston, MA 02284-2772
Phone (513) 762-1090

Other identifiers 2

NPPES NPI Registry
IdentifierTypeStateIssuer
2042693OtherPK
2369937MedicaidMI

Other names 1

NPPES NPI Registry
  • KROGER PHARMACY Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Jan 16, 2019.

{
    "created_epoch": "1184803200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1547596800000",
    "number": "1548460488",
    "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": "513-762-1090"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1821 S CEDAR ST",
            "city": "IMLAY CITY",
            "state": "MI",
            "postal_code": "484441344",
            "telephone_number": "810-721-3262",
            "fax_number": "810-721-3263"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KROGER CO OF MICHIGAN",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-07-19",
        "last_updated": "2019-01-16",
        "status": "A",
        "authorized_official_last_name": "WARMAN",
        "authorized_official_first_name": "JESSIE",
        "authorized_official_title_or_position": "MANAGER RX LICENSING",
        "authorized_official_telephone_number": "513-762-1090"
    },
    "taxonomies": [
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MI",
            "license": "5301008654",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2042693",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2369937",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KROGER PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "KROGER PHARMACY",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Imlay City, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 16, 2019; 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.