Provider Demographics
NPI:1730135120
Name:SHAWS SUPERMARKETS INC
Entity Type:Organization
Organization Name:SHAWS SUPERMARKETS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3905
Mailing Address - Street 1:3030 CULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 KITTS LN
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4250
Practice Address - Country:US
Practice Address - Phone:860-594-7123
Practice Address - Fax:860-594-7131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CT15863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004161684Medicaid
0716766OtherNCPDP PROVIDER IDENTIFICATION NUMBER
0716766OtherNCPDP PROVIDER IDENTIFICATION NUMBER