Provider Demographics
NPI:1881707271
Name:PRICE CHOPPER INC
Entity type:Organization
Organization Name:PRICE CHOPPER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAINELLA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:518-379-1618
Mailing Address - Street 1:521 DUANESBURG RD
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12306-1054
Mailing Address - Country:US
Mailing Address - Phone:518-379-1618
Mailing Address - Fax:518-356-6978
Practice Address - Street 1:943 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1301
Practice Address - Country:US
Practice Address - Phone:203-591-8468
Practice Address - Fax:203-591-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY18313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234895Medicaid
CT1261670002Medicare ID - Type Unspecified
1261670002Medicare NSC