1700818663 NPI number — STOP AND SHOP SUPERMARKET CO LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700818663 NPI number — STOP AND SHOP SUPERMARKET CO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STOP AND SHOP SUPERMARKET CO LLC
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:
STOP AND SHOP PHARMACY #667
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:
1700818663
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 BOSTON POST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06385-2400
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:
117 BOSTON POST RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06385-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-442-6698
Provider Business Practice Location Address Fax Number:
860-443-4807
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAYTON
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
617-770-8782

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1260 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 1260 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 1260 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0712011 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 940004064093 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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