NPIMap

Organization Active NPI

Kroger Co of Michigan

Doing business as Kroger Pharmacy

  • Community/Retail Pharmacy
  • Grosse Pointe, MI
National Provider Identifier
1609076520
Registry record updated Jan 16, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
5301008652 Issued in MI
Legal business name
KROGER CO OF MICHIGAN
Doing business as
Kroger Pharmacy
Practice address
20422 Mack Ave
Grosse Pointe, MI 48236-1676
Phone
(313) 308-1033
Fax
(313) 308-1036
NPI assigned
Jul 19, 2007
Last updated
Jan 16, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 16, 2019

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community/Retail Pharmacy 3336C0003X 5301008652 MI Primary

Addresses

Primary practice location

20422 Mack Ave
Grosse Pointe, MI 48236-1676

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
2042701OtherPK
2370017MedicaidMI

Other names 1

  • KROGER PHARMACY 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
O20100930060254 MI DME Supplier - PharmacyDME Supplier - Grocery Store 8820051816 Practice locations: Grosse Pointe Woods, 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
23D2077073Kroger Pharmacy20422 Mack Avenue, Grosse Pointe Woods, MI 48236Certificate of waiverApr 29, 2028

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Kroger Pharmacy 45420422 Mack Ave, Grosse Pointe Woods, MI 48236-1676(313) 308-1033 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.

Locations

20422 Mack Ave
Grosse Pointe Woods, MI 48236
Phone (313) 308-1033

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": "1547596800000",
    "number": "1609076520",
    "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": "20422 MACK AVE",
            "city": "GROSSE POINTE",
            "state": "MI",
            "postal_code": "482361676",
            "telephone_number": "313-308-1033",
            "fax_number": "313-308-1036"
        }
    ],
    "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": "5301008652",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2042701",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2370017",
            "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 Grosse Pointe, 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.