Provider Demographics
NPI:1952416737
Name:INSERRA SUPERMARKET INC
Entity type:Organization
Organization Name:INSERRA SUPERMARKET INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGUEROA RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-521-8439
Mailing Address - Street 1:PO BOX 21158
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-1158
Mailing Address - Country:US
Mailing Address - Phone:845-353-4949
Mailing Address - Fax:845-353-3993
Practice Address - Street 1:243 ROUTE 59
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-2036
Practice Address - Country:US
Practice Address - Phone:845-353-4949
Practice Address - Fax:845-353-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
NY019616333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01056862Medicaid
3390919OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3390919OtherOTHER ID NUMBER-COMMERCIAL NUMBER