Provider Demographics
NPI:1508898453
Name:STOP AND SHOP SUPERMARKET CO LLC
Entity Type:Organization
Organization Name:STOP AND SHOP SUPERMARKET CO LLC
Other - Org Name:STOP AND SHOP PHARMACY #504
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, THIRD PARTY PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-240-1526
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-240-5520
Mailing Address - Fax:717-960-8371
Practice Address - Street 1:691 CO OP CITY BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1673
Practice Address - Country:US
Practice Address - Phone:718-862-2883
Practice Address - Fax:718-862-3276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24817332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3318296OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02090297Medicaid
3318296OtherOTHER ID NUMBER-COMMERCIAL NUMBER