=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235236001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHMARK STORES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2060 SUNRISE HWY
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-6018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-666-5501
-----------------------------------------------------
Fax | 631-666-4680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 PARAGON DR
-----------------------------------------------------
City | MONTVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07645-1718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-573-9700
-----------------------------------------------------
Fax | 201-571-8335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REG COMPLIANCE SPECIALIST
-----------------------------------------------------
Name | SUSAN D KIJOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-571-8326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 015200
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------