Healthcare Provider Details

I. General information

NPI: 1962509737
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: 08/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5145 NESCONSET HWY
PORT JEFFERSON STATION NY
11776-2047
US

IV. Provider business mailing address

PO BOX 416369
BOSTON MA
02241-6369
US

V. Phone/Fax

Practice location:
  • Phone: 631-331-2210
  • Fax: 631-473-3291
Mailing address:
  • Phone: 201-571-4568
  • Fax: 201-571-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number016040
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number016040
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUSAN D KIJOWSKI
Title or Position: MANAGER, REGULATORY COMPLIANCE
Credential:
Phone: 201-571-8326