Healthcare Provider Details

I. General information

NPI: 1285733253
Provider Name (Legal Business Name): PATHMARK STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 RT 130
BEVERLY NJ
08010
US

IV. Provider business mailing address

2 PARAGON DR
MONTVALE NJ
07645-1718
US

V. Phone/Fax

Practice location:
  • Phone: 609-871-1550
  • Fax: 609-877-7719
Mailing address:
  • Phone: 201-573-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS02202
License Number StateNJ

VIII. Authorized Official

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