Provider Demographics
NPI:1821013384
Name:GREAT ATLANTIC & PACIFIC TEA COMPANY INC
Entity Type:Organization
Organization Name:GREAT ATLANTIC & PACIFIC TEA COMPANY INC
Other - Org Name:A & P PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, REGULATORY COMPLIANCE
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:PO BOX 416369
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3105 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1521
Practice Address - Country:US
Practice Address - Phone:914-526-0240
Practice Address - Fax:914-526-0244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023501332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01815627Medicaid
NY018156270442OtherMEDICAID DME
3332741OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY01815627Medicaid