Healthcare Provider Details

I. General information

NPI: 1891727772
Provider Name (Legal Business Name): STOP AND SHOP SUPERMARKET CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 HOWLEY ST
PEABODY MA
01960-5617
US

IV. Provider business mailing address

19 HOWLEY ST
PEABODY MA
01960-5617
US

V. Phone/Fax

Practice location:
  • Phone: 978-977-3946
  • Fax: 978-977-5323
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2868
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2868
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2868
License Number StateMA

VIII. Authorized Official

Name: BRAD DAYTON
Title or Position: DIRECTOR
Credential:
Phone: 617-770-8782