Provider Demographics
NPI:1184728313
Name:BRACEYS SUPERMARKET INC.
Entity type:Organization
Organization Name:BRACEYS SUPERMARKET INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:921 DRINKER TPKE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-7947
Mailing Address - Country:US
Mailing Address - Phone:570-842-7461
Mailing Address - Fax:570-842-6520
Practice Address - Street 1:ROUTE 502
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:PA
Practice Address - Zip Code:18444
Practice Address - Country:US
Practice Address - Phone:570-842-7848
Practice Address - Fax:570-842-2435
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRACEYS SUPERMARKET INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-08
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415521L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3975743OtherNCPDP
PA0017474490001Medicaid
PA0017474490001Medicaid
PA1275560001Medicare NSC