Provider Demographics
NPI:1114035599
Name:MARTINS FOODS OF SOUTH BURLINGTON LLC
Entity Type:Organization
Organization Name:MARTINS FOODS OF SOUTH BURLINGTON LLC
Other - Org Name:HANNAFORD FOOD AND DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VAIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:MS 3000
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:704-645-6531
Practice Address - Street 1:1122 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-3751
Practice Address - Country:US
Practice Address - Phone:315-235-0204
Practice Address - Fax:315-235-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NY0276913336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2067535OtherPK
NY02744003Medicaid
2067535OtherPK
0365310042Medicare NSC