Provider Demographics
NPI:1477578938
Name:WALDBAUM INC
Entity Type:Organization
Organization Name:WALDBAUM INC
Other - Org Name:WALDBAUMS 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:
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:2162 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2162 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3503
Practice Address - Country:US
Practice Address - Phone:631-444-0968
Practice Address - Fax:631-444-0963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2007-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023413332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01777137Medicaid
3328095OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3328095OtherOTHER ID NUMBER-COMMERCIAL NUMBER