Healthcare Provider Details

I. General information

NPI: 1154356186
Provider Name (Legal Business Name): STOP & SHOP SUPERMARKET COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

932 N MONTELLO ST
BROCKTON MA
02301-1671
US

IV. Provider business mailing address

932 N MONTELLO ST
BROCKTON MA
02301-1671
US

V. Phone/Fax

Practice location:
  • Phone: 508-427-6582
  • Fax: 508-427-6977
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3290
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number3290
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number3290
License Number StateMA

VIII. Authorized Official

Name: GORDON REID
Title or Position: PRESIDENT
Credential:
Phone: 301-341-3906