Healthcare Provider Details

I. General information

NPI: 1275630030
Provider Name (Legal Business Name): PATHMARK STORES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 GRAND ST
JERSEY CITY NJ
07302-4240
US

IV. Provider business mailing address

2 PARAGON DR
MONTVALE NJ
07645-1718
US

V. Phone/Fax

Practice location:
  • Phone: 201-432-5513
  • Fax: 201-432-2261
Mailing address:
  • Phone: 201-573-9700
  • Fax: 201-571-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number28RS00362900
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS003629
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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