Provider Demographics
NPI:1568449056
Name:GRISTEDES OPERATING CORP
Entity Type:Organization
Organization Name:GRISTEDES OPERATING CORP
Other - Org Name:GRISTEDES PHARMACY 90
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 1:1100 WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-6863
Mailing Address - Country:US
Mailing Address - Phone:914-725-4931
Mailing Address - Fax:914-725-4607
Practice Address - Street 1:1100 WILMOT RD
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-6863
Practice Address - Country:US
Practice Address - Phone:914-725-4931
Practice Address - Fax:914-725-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024303333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3305516OtherNCPDP
NY02050219Medicaid
BG6242705OtherDEA