Healthcare Provider Details

I. General information

NPI: 1962685909
Provider Name (Legal Business Name): STOP & SHOP SUPERMARKET COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2007
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 MONTAUK HWY
SHIRLEY NY
11967-2130
US

IV. Provider business mailing address

999 MONTAUK HWY
SHIRLEY NY
11967-2130
US

V. Phone/Fax

Practice location:
  • Phone: 631-281-3610
  • Fax: 631-281-8924
Mailing address:
  • Phone: 631-281-3610
  • Fax: 631-281-8924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier3357084
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerNCPDP
# 2
Identifier02949237
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: BRAD DAYTON
Title or Position: DIRECTOR PHARMACY SYSTEMS
Credential:
Phone: 617-770-8782