Healthcare Provider Details

I. General information

NPI: 1033141999
Provider Name (Legal Business Name): STOP AND SHOP SUPERMARKET CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 POND PATH
SOUTH SETAUKET NY
11720-2006
US

IV. Provider business mailing address

250 POND PATH
SOUTH SETAUKET NY
11720-2006
US

V. Phone/Fax

Practice location:
  • Phone: 631-585-4469
  • Fax: 631-585-4331
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number025642
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number025642
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number025642
License Number StateNY

VIII. Authorized Official

Name: BOB STONE
Title or Position: DIR 3RD PARTY MANAGED CARE
Credential:
Phone: 781-380-5609