Provider Demographics
NPI:1639103591
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 #543
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 1:365 ROUTE 109
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:365 ROUTE 109
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6213
Practice Address - Country:US
Practice Address - Phone:631-587-9455
Practice Address - Fax:631-661-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026648332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3336953OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02554350Medicaid
3336953OtherOTHER ID NUMBER-COMMERCIAL NUMBER