Provider Demographics
NPI:1972708758
Name:PRICE CHOPPER INC
Entity Type:Organization
Organization Name:PRICE CHOPPER INC
Other - Org Name:PRICE CHOPPER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-379-1122
Mailing Address - Street 1:461 NOTT ST
Mailing Address - Street 2:MB#202
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-1812
Mailing Address - Country:US
Mailing Address - Phone:518-379-1618
Mailing Address - Fax:518-356-6978
Practice Address - Street 1:675 POQUONCOCK AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095
Practice Address - Country:US
Practice Address - Phone:860-687-1910
Practice Address - Fax:860-687-9838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY000020943336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2002828OtherPK
CT004270732Medicaid
CT004270732Medicaid
2002828OtherPK