Provider Demographics
NPI:1740790278
Name:ACME MARKETS INC
Entity Type:Organization
Organization Name:ACME MARKETS INC
Other - Org Name:ACME PHARMACY #1096
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT MANAGER, ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3906
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 KENILWORTH BLVD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:NJ
Practice Address - Zip Code:07033-1719
Practice Address - Country:US
Practice Address - Phone:908-259-0720
Practice Address - Fax:908-259-0730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NJ28RS005268003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0521574Medicaid