1811094675 NPI number — PATHMARK STORES INC

Table of content: (NPI 1811094675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811094675 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 #580
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:
1811094675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 416369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-6369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-571-8326
Provider Business Mailing Address Fax Number:
201-571-8335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 SAINT GEORGES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVENEL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07001-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-499-7904
Provider Business Practice Location Address Fax Number:
732-943-1479
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:
MANAGER, REGULATORY COMPLIANCE
Authorized Official Telephone Number:
201-571-8326

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  RS28002936 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 28RS00293600 , registered in the state of NJ ; 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: 4326300 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3122330 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".