Provider Demographics
NPI:1679686778
Name:PRICE CHOPPER INC
Entity Type:Organization
Organization Name:PRICE CHOPPER INC
Other - Org Name:PRICE CHOPPER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-379-1122
Mailing Address - Street 1:461 NOTT ST
Mailing Address - Street 2:MB#202
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-1812
Mailing Address - Country:US
Mailing Address - Phone:518-379-1618
Mailing Address - Fax:518-356-6978
Practice Address - Street 1:990 TORRINGFORD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3542
Practice Address - Country:US
Practice Address - Phone:860-496-5058
Practice Address - Fax:860-496-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
CTPCY016123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004167509Medicaid
2001744OtherPK
D30000921Medicare PIN
1261670001Medicare NSC