Healthcare Provider Details

I. General information

NPI: 1003036385
Provider Name (Legal Business Name): BIG Y FOODS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 WAUREGAN RD
DANIELSON CT
06239-3712
US

IV. Provider business mailing address

2145 ROOSEVELT AVE
SPRINGFIELD MA
01104-1650
US

V. Phone/Fax

Practice location:
  • Phone: 860-774-7437
  • Fax: 860-774-0391
Mailing address:
  • Phone: 413-504-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPCY.1288
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPCY.1288
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier004268422
Identifier TypeMEDICAID
Identifier StateCT
Identifier Issuer
# 2
IdentifierPCY.1288
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerSTATE OF CT BOARD OF PHAR

VIII. Authorized Official

Name: MR. MICHAEL S GOLD
Title or Position: VP, ASSISTANT SECRETARY
Credential:
Phone: 413-504-4492