1124074125 NPI number — ACME MARKETS INC

Table of content: (NPI 1124074125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124074125 NPI number — ACME MARKETS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACME MARKETS INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SAV-ON PHARMACY #2977
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124074125
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 E PARKCENTER BLVD
Provider Second Line Business Mailing Address:
MAILSTOP SEC2-B
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6800 NEW FALLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEVITTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-946-1597
Provider Business Practice Location Address Fax Number:
215-949-3792
Provider Enumeration Date:
05/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ELIOPULOS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT MANAGER, ENROLLMENTS
Authorized Official Telephone Number:
208-395-3906

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP415103L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1007619290054 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2083052 . This is a "PK" identifier . This identifiers is of the category "OTHER".