1932131802 NPI number — STOP AND SHOP SUPERMARKET CO LLC

Table of content: (NPI 1932131802)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932131802 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 #663
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:
1932131802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1149 HARRISBURG PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLISLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17013-1607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-240-5520
Provider Business Mailing Address Fax Number:
717-960-8371

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1360 E TOWN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06460-3623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-877-1912
Provider Business Practice Location Address Fax Number:
203-874-7438
Provider Enumeration Date:
07/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FARRELL
Authorized Official First Name:
ALISON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PHARMACY THIRD PARTY
Authorized Official Telephone Number:
717-240-5520

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  1622 , 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: 1622 , 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: 1622 , 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: 0717148 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 940004173986 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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