Provider Demographics
NPI:1396842167
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:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:MINDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NORELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-499-3313
Mailing Address - Street 1:200 MILIK ST
Mailing Address - Street 2:M115
Mailing Address - City:CARTERET
Mailing Address - State:NJ
Mailing Address - Zip Code:07008-1102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2506 KNIGHTS RD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-3400
Practice Address - Country:US
Practice Address - Phone:215-639-0100
Practice Address - Fax:215-639-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP410975L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0394687Medicaid
3946879OtherOTHER ID NUMBER-COMMERCIAL NUMBER