Provider Demographics
NPI:1912953308
Name:SHAWS SUPERMARKETS INC
Entity Type:Organization
Organization Name:SHAWS SUPERMARKETS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3905
Mailing Address - Street 1:3030 CULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3680
Practice Address - Country:US
Practice Address - Phone:860-314-2710
Practice Address - Fax:860-314-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CTPCY00006183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0716475OtherNCPDP PROVIDER IDENTIFICATION NUMBER
CT004114443Medicaid
0716475OtherNCPDP PROVIDER IDENTIFICATION NUMBER