1528079191 NPI number — GERRITYS SUPERMARKET INC

Table of content: (NPI 1528079191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528079191 NPI number — GERRITYS SUPERMARKET INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERRITYS 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:
GERRITYS PHARMACY HANOVER
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:
1528079191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 N SOUTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SCRANTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18504-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-342-4144
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2280 SANS SOUCI PKWY
Provider Second Line Business Practice Location Address:
HANOVER MALL
Provider Business Practice Location Address City Name:
HANOVER TOWNSHIP
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18706-5049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-812-0016
Provider Business Practice Location Address Fax Number:
570-812-0017
Provider Enumeration Date:
08/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DENTE
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MGR
Authorized Official Telephone Number:
570-812-0016

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  PP481598 , 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: 1016870200001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2087853 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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