Provider Demographics
NPI:1790706026
Name:PENN TRAFFIC COMPANY THE
Entity Type:Organization
Organization Name:PENN TRAFFIC COMPANY THE
Other - Org Name:P AND C FOOD AND PHARMACY 3040
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY SYSTEMS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ERBA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:315-461-2595
Mailing Address - Street 1:2078 STATE ROUTE 481
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2078 STATE ROUTE 481
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069
Practice Address - Country:US
Practice Address - Phone:315-592-3595
Practice Address - Fax:315-592-4889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022164333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01483843Medicaid
3348112OtherOTHER ID NUMBER-COMMERCIAL NUMBER