MEDICARE: PATHMARK STORES 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	PP414226L	PA
3	333600000X	Pharmacy	PP414226L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	3958571	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1205933074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHMARK STORES INC

Provider Business Mailing Address
First Line	:	2 PARAGON DR
Second Line	:
City	:	MONTVALE
State	:	NJ
Zip	:	07645-1718
Country	:	US
Telephone Number	:	201-573-9700
Fax Number	:	201-571-8335

Provider Business Practice Location Address
First Line	:	3021 GRAYS FERRY AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-2709
Country	:	US
Telephone Number	:	215-551-7284
Fax Number	:	215-468-5218

Authorized Official
Title or Position	:	PHARMACY SPECIALIST
Name	:	SUSAN D KIJOWSKI
Credential	:
Telephone Number	:	201-571-8326

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	06/27/2008

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Directions to “PATHMARK STORES INC ” Practice Location

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