Provider Demographics
NPI:1023281540
Name:PENN TRAFFIC COMPANY, THE
Entity type:Organization
Organization Name:PENN TRAFFIC COMPANY, THE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CORPROATE COUNCIL
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAHONEY
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:315-461-2347
Mailing Address - Street 1:1200 STATE FAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13209-1070
Mailing Address - Country:US
Mailing Address - Phone:315-461-2600
Mailing Address - Fax:315-461-2304
Practice Address - Street 1:1200 STATE FAIR BLVD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13209-1070
Practice Address - Country:US
Practice Address - Phone:315-461-2600
Practice Address - Fax:315-461-2304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
449OtherNCPDP CHAIN CODE
454OtherNCPDP CHAIN CODE
452OtherNCPCP CHAIN CODE
993OtherNCPDP FRANCHISE CODE