1639689367 NPI number — ACME MARKETS INC

Table of content: (NPI 1639689367)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639689367 NPI number — ACME MARKETS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ACME MARKETS 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:
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:
1639689367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 E PARKCENTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-3940
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:
5100 WELLINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENTNOR CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08406-1445
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-823-0087
Provider Business Practice Location Address Fax Number:
609-823-0097
Provider Enumeration Date:
10/09/2017

Additional Information

Authorized Official

Authorized Official Last Name:
ELIOPULOS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT MANAGER, ENROLLMENTS
Authorized Official Telephone Number:
208-395-3906

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 28RS00614200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0527017 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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