Provider Demographics
NPI:1740205202
Name:WALDBAUM INC
Entity Type:Organization
Organization Name:WALDBAUM INC
Other - Org Name:WALDBAUMS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:60 WALL ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2065
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:60 WALL ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2065
Practice Address - Country:US
Practice Address - Phone:631-421-0134
Practice Address - Fax:631-385-7008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021419332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3324415OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY01363900Medicaid
NY013639000442OtherMEDICAID DME
NY0711830013Medicare NSC