Provider Demographics
NPI:1982701744
Name:PATHMARK STORES INC
Entity Type:Organization
Organization Name:PATHMARK STORES INC
Other - Org Name:PATHMARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST
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 1:2 PARAGON DR
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1718
Mailing Address - Country:US
Mailing Address - Phone:201-573-9700
Mailing Address - Fax:201-571-8335
Practice Address - Street 1:492 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1517
Practice Address - Country:US
Practice Address - Phone:516-599-2283
Practice Address - Fax:516-596-3285
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA COMPANY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013584333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00383344Medicaid
3313842OtherOTHER ID NUMBER-COMMERCIAL NUMBER