Provider Demographics
NPI:1982636833
Name:STOP AND SHOP SUPERMARKET CO LLC
Entity Type:Organization
Organization Name:STOP AND SHOP SUPERMARKET CO LLC
Other - Org Name:STOP AND SHOP PHARMACY 563
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR 3RD PARTY MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-770-6257
Mailing Address - Street 1:5701 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5701 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4801
Practice Address - Country:US
Practice Address - Phone:631-218-8636
Practice Address - Fax:516-218-8630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY24780332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02079812Medicaid
3314692OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02079812Medicaid