Provider Demographics
NPI:1609808559
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 #583
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-770-8782
Mailing Address - Street 1:70030 PATCHOGUE YAPHANK ROAD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70030 PATCHOGUE YAPHANK ROAD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763
Practice Address - Country:US
Practice Address - Phone:631-345-0255
Practice Address - Fax:516-345-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024785332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02079954Medicaid
3314767OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY0575340165Medicare NSC