1154357937 NPI number — GENUARDI'S FAMILY MARKETS LP GFM

Table of content: (NPI 1154357937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154357937 NPI number — GENUARDI'S FAMILY MARKETS LP GFM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENUARDI'S FAMILY MARKETS LP GFM
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:
Provider Other Organization Name Type Code:
6
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:
1154357937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20427 N 27TH AVE
Provider Second Line Business Mailing Address:
MAIL STOP 4551
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85027-3241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-869-3602
Provider Business Mailing Address Fax Number:
623-869-1924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2350 SUSQUEHANNA ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSLYN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-881-9508
Provider Business Practice Location Address Fax Number:
215-881-9802
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TITUS
Authorized Official First Name:
DELLA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE PLAN SPECIALIST
Authorized Official Telephone Number:
623-869-3602

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PP481059 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01914977 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3978989 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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