Provider Demographics
NPI:1629099940
Name:PENN TRAFFIC CO
Entity Type:Organization
Organization Name:PENN TRAFFIC CO
Other - Org Name:BILO FOODS AND PHARMACY 9003
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:315-461-2347
Mailing Address - Street 1:1200 STATE FAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1888
Practice Address - Country:US
Practice Address - Phone:814-371-9000
Practice Address - Fax:814-375-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP412682L333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3961035OtherNCPDP
3961035OtherOTHER ID NUMBER-COMMERCIAL NUMBER
PA01215180Medicaid
1007783900001OtherPA PROMISE- MEDICAID
3961035OtherNCPDP