Provider Demographics
NPI:1497732515
Name:GRISTEDES FOODS INC
Entity Type:Organization
Organization Name:GRISTEDES FOODS INC
Other - Org Name:GRISTEDES PHARMACY 560
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-217-2789
Mailing Address - Street 1:2109 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:212-787-4076
Mailing Address - Fax:212-787-4083
Practice Address - Street 1:2109 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-787-4076
Practice Address - Fax:212-787-4083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025551333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3329201OtherNCPDP
NY02380463Medicaid
NY02380463Medicaid