1184728313 NPI number — BRACEYS SUPERMARKET INC.

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 1184728313 NPI number — BRACEYS SUPERMARKET INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRACEYS SUPERMARKET 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:
BILL'S SHOPRITE PHARMACY
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:
1184728313
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 DRINKER TPKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON TOWNSHIP
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18444-7947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-842-7461
Provider Business Mailing Address Fax Number:
570-842-6520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
ROUTE 502
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALEVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-842-7848
Provider Business Practice Location Address Fax Number:
570-842-2435
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FIGUEROA RIVERA
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
THIRD PARTY ADMINISTRATOR
Authorized Official Telephone Number:
732-521-8439

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP415521L , 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: 3975743 . This is a "NCPDP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017474490001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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