Healthcare Provider Details

I. General information

NPI: 1851316400
Provider Name (Legal Business Name): THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 11/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1238 PUTTY HILL AVE
TOWSON MD
21286-5844
US

IV. Provider business mailing address

1238 PUTTY HILL AVE
TOWSON MD
21286-5844
US

V. Phone/Fax

Practice location:
  • Phone: 410-583-1626
  • Fax: 410-583-1694
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberP02405
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberP02405
License Number StateMD

VII. Legacy identifiers

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

# 1
Identifier2123583
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER

VIII. Authorized Official

Name: SUSAN KIJOWSKI
Title or Position: PHARMACY SPECIALIST
Credential:
Phone: 201-571-8326