Healthcare Provider Details

I. General information

NPI: 1477751675
Provider Name (Legal Business Name): THE GREAT ATLANTIC & PACIFIC TEA CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 OLD TAPPAN ROAD
OLD TAPPAN NJ
07675
US

IV. Provider business mailing address

216 OLD TAPPAN ROAD
OLD TAPPAN NJ
07675
US

V. Phone/Fax

Practice location:
  • Phone: 201-391-0639
  • Fax: 201-391-1845
Mailing address:
  • Phone: 201-391-0639
  • Fax: 201-391-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number06711
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number06711
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License NumberRS00671100
License Number StateNJ

VIII. Authorized Official

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