Provider Demographics
NPI:1831483007
Name:PATCHOGUE SUPERMARKETS LLC
Entity Type:Organization
Organization Name:PATCHOGUE SUPERMARKETS LLC
Other - Org Name:PATCHOGUE SUPERMARKETS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:P.O. BOX 15169
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07192
Mailing Address - Country:US
Mailing Address - Phone:631-286-5030
Mailing Address - Fax:
Practice Address - Street 1:95 SUNRISE HWY W
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1847
Practice Address - Country:US
Practice Address - Phone:631-286-5030
Practice Address - Fax:631-286-5031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0309213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03395631Medicaid
2132354OtherPK
5803641OtherNCPDP PROVIDER IDENTIFICATION NUMBER