Provider Demographics
NPI:1457721680
Name:STOP & SHOP SUPERMARKET COMPANY, LLC
Entity type:Organization
Organization Name:STOP & SHOP SUPERMARKET COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-883-2911
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:ATTN: THIRD PARTY COORDINATOR
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-960-8553
Mailing Address - Fax:717-960-1389
Practice Address - Street 1:1351 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2049
Practice Address - Country:US
Practice Address - Phone:718-448-6758
Practice Address - Fax:718-981-0540
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHOLDUSA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-30
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034058OtherSTATE LICENSE
NYFT5738971OtherDEA LICENSE
NY0575340347Medicare NSC