1699872457 NPI number — PATHMARK STORES 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 1699872457 NPI number — PATHMARK STORES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHMARK STORES 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:
PATHMARK 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:
1699872457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 PARAGON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTVALE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07645-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-573-9700
Provider Business Mailing Address Fax Number:
201-571-8335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2875 RICHMOND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10314-5811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-761-8484
Provider Business Practice Location Address Fax Number:
718-370-8863
Provider Enumeration Date:
09/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIJOWSKI
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
REGULATORY COMPLIANCE SPECIALIST
Authorized Official Telephone Number:
201-571-8326

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  013444 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 013444 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 00264782 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3313993 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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