Provider Demographics
NPI:1811094675
Name:PATHMARK STORES INC
Entity type:Organization
Organization Name:PATHMARK STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, REGULATORY COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:PO BOX 416369
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6369
Mailing Address - Country:US
Mailing Address - Phone:201-571-8326
Mailing Address - Fax:201-571-8335
Practice Address - Street 1:1600 SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:AVENEL
Practice Address - State:NJ
Practice Address - Zip Code:07001-1044
Practice Address - Country:US
Practice Address - Phone:732-499-7904
Practice Address - Fax:732-943-1479
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA COMPANY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NJRS28002936332B00000X
NJ28RS00293600333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4326300Medicaid
3122330OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3122330OtherOTHER ID NUMBER-COMMERCIAL NUMBER