Provider Demographics
NPI:1144404344
Name:BIG Y FOODS, INC.
Entity Type:Organization
Organization Name:BIG Y FOODS, INC.
Other - Org Name:BIG Y PHARMACY #84
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, ASSISTANT SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1413-504-4492
Mailing Address - Street 1:2145 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-1650
Mailing Address - Country:US
Mailing Address - Phone:413-504-4492
Mailing Address - Fax:413-504-5492
Practice Address - Street 1:355 HAWLEY LANE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614
Practice Address - Country:US
Practice Address - Phone:413-504-4492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY.2103332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000241Medicaid
CTPCY.2103OtherPHARMACY LIC #
4259010032Medicare NSC