Provider Demographics
NPI:1083646954
Name:STOP AND SHOP SUPERMARKET CO LLC
Entity Type:Organization
Organization Name:STOP AND SHOP SUPERMARKET CO LLC
Other - Org Name:STOP & SHOP PHARMACY 2418
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARKIEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-240-1543
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-960-8553
Mailing Address - Fax:
Practice Address - Street 1:126 MEDWAY RD
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2915
Practice Address - Country:US
Practice Address - Phone:508-478-5748
Practice Address - Fax:508-478-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1621332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0435708Medicaid
2228686OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MA0575340014Medicare NSC