Healthcare Provider Details

I. General information

NPI: 1003913864
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: 03/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KINNELON RD
KINNELON NJ
07405-2337
US

IV. Provider business mailing address

2 PARAGON DR
MONTVALE NJ
07645-1718
US

V. Phone/Fax

Practice location:
  • Phone: 973-838-6699
  • Fax: 973-838-1236
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 NumberRS2800325300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS002015
License Number StateNJ

VIII. Authorized Official

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