Provider Demographics
NPI:1295950350
Name:SUPER FRESH FOOD MARKETS, INC.
Entity type:Organization
Organization Name:SUPER FRESH FOOD MARKETS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, PHARMACY
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:DINICOLANTONIO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH MBA
Authorized Official - Phone:201-571-8334
Mailing Address - Street 1:616 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-2964
Mailing Address - Country:US
Mailing Address - Phone:215-855-5606
Mailing Address - Fax:215-855-6097
Practice Address - Street 1:616 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-2964
Practice Address - Country:US
Practice Address - Phone:215-855-5606
Practice Address - Fax:215-855-6097
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA CO., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-16
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4811103336C0003X, 332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3987572OtherNCPDP #
PA1007725100056Medicaid
PAPP481110OtherSTATE LICENSE
PA3987572OtherNCPDP #