MEDICARE: GREAT ATLANTIC & PACIFIC TEA COMPANY INC

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	3336C0003X	Community/Retail Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies	05371	NJ
3	333600000X	Pharmacy	05371	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	3138268	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134144793
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT ATLANTIC & PACIFIC TEA COMPANY INC

Provider Business Mailing Address
First Line	:	PO BOX 416369
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-6369
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	152 RTE 94
Second Line	:
City	:	BLAIRSTOWN
State	:	NJ
Zip	:	07825
Country	:	US
Telephone Number	:	908-362-9388
Fax Number	:	908-362-9372

Authorized Official
Title or Position	:	MANAGER, REGULATORY COMPLIANCE
Name	:	SUSAN KIJOWSKI
Credential	:
Telephone Number	:	201-571-8326

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	10/10/2011

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Directions to “GREAT ATLANTIC & PACIFIC TEA COMPANY INC ” Practice Location

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