Provider Demographics
NPI:1275648057
Name:RACETRACK SUPERMARKET LLC
Entity Type:Organization
Organization Name:RACETRACK SUPERMARKET LLC
Other - Org Name:SHOPRITE PHARMACY
Other - Org Type:Doing Business As
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:PO BOX 15169
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07192-5169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2230 ROUTE 70 W # 40
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3338
Practice Address - Country:US
Practice Address - Phone:856-910-2320
Practice Address - Fax:856-910-2322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NJ28RS005696003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2054068OtherPK
NJ7845103Medicaid
0794430001Medicare NSC