Provider Demographics
NPI:1942225594
Name:THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Entity Type:Organization
Organization Name:THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Other - Org Name:SUPER FRESH 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 1:37 W AYLESBURY RD
Mailing Address - Street 2:
Mailing Address - City:TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:37 W AYLESBURY RD
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-4102
Practice Address - Country:US
Practice Address - Phone:410-308-8702
Practice Address - Fax:410-308-8705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP02311332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2122973OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MD0721470055Medicare NSC