Provider Demographics
NPI:1396888418
Name:AMMONS SUPERMARKET LLC
Entity type:Organization
Organization Name:AMMONS SUPERMARKET LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:MISS
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 1:3745 ARAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19137-1001
Mailing Address - Country:US
Mailing Address - Phone:215-288-2828
Mailing Address - Fax:215-288-7314
Practice Address - Street 1:3745 ARAMINGO AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19137-1001
Practice Address - Country:US
Practice Address - Phone:215-288-2828
Practice Address - Fax:215-288-7314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415496L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3975224OtherNCPDP
PA0017895380001Medicaid
PAPP415496LOtherSTATE LICENSE
PAPP415496LOtherSTATE LICENSE