Healthcare Provider Details

I. General information

NPI: 1053418814
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: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2660 HYLAN BLVD
STATEN ISLAND NY
10306-4355
US

IV. Provider business mailing address

200 MILIK ST M115
CARTERET NJ
07008-1102
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-1005
  • Fax: 718-980-5512
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number014471
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MINDI NORELLI
Title or Position: ADMIN
Credential:
Phone: 732-499-3313