Provider Demographics
NPI:1275630030
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 1:422 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4240
Practice Address - Country:US
Practice Address - Phone:201-432-5513
Practice Address - Fax:201-432-2261
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC AND PACIFIC TEA CO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS00362900332B00000X
NJRS003629333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4360702Medicaid
3126770OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ4360702Medicaid