=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962509737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATHMARK STORES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 08/16/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5145 NESCONSET HWY
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-331-2210
-----------------------------------------------------
Fax | 631-473-3291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 416369
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02241-6369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-571-4568
-----------------------------------------------------
Fax | 201-571-8335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER, REGULATORY COMPLIANCE
-----------------------------------------------------
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 | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 016040
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 016040
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------