MEDICARE: STOP AND SHOP SUPERMARKET CO LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	026854	NY
2	332B00000X	Durable Medical Equipment & Medical Supplies	026854	NY
3	3336C0003X	Community/Retail Pharmacy	026854	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3339618	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114959079
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOP AND SHOP SUPERMARKET CO LLC

Provider Business Mailing Address
First Line	:	425 PORTION RD
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4579
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 PORTION RD
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4579
Country	:	US
Telephone Number	:	631-737-1736
Fax Number	:	631-737-2879

Authorized Official
Title or Position	:	DIRECTOR
Name	:	BRAD DAYTON
Credential	:
Telephone Number	:	617-770-8782

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	10/19/2011

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