Provider Demographics
NPI:1114024981
Name:PATHMARK STORES INC
Entity Type:Organization
Organization Name:PATHMARK STORES INC
Other - Org Name:PATHMARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:2 PARAGON DR
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1718
Mailing Address - Country:US
Mailing Address - Phone:201-573-9700
Mailing Address - Fax:201-571-8335
Practice Address - Street 1:2900 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-2400
Practice Address - Country:US
Practice Address - Phone:215-226-0446
Practice Address - Fax:215-226-0781
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA CO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415487L332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017374600002Medicaid
3975604OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA0017374600002Medicaid