Provider Demographics
NPI:1477751675
Name:THE GREAT ATLANTIC & PACIFIC TEA CO., INC.
Entity type:Organization
Organization Name:THE GREAT ATLANTIC & PACIFIC TEA CO., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:216 OLD TAPPAN ROAD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:201-391-0639
Mailing Address - Fax:201-391-1845
Practice Address - Street 1:216 OLD TAPPAN ROAD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675
Practice Address - Country:US
Practice Address - Phone:201-391-0639
Practice Address - Fax:201-391-1845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS006711003336M0002X
NJ06711332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD09109200OtherNJ STATE CDS LICENSE
NJRS00671100OtherNJ STATE PHARMACY LICENSE
NJ3194470OtherNCPDP #
NJ3194470OtherNCPDP #