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	017766	NY
3	333600000X	Pharmacy	017766	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3376426	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225135098
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	:	201-571-8326
Fax Number	:	201-571-8335

Provider Business Practice Location Address
First Line	:	130 MIDLAND AVE
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-4916
Country	:	US
Telephone Number	:	914-937-0996
Fax Number	:	914-937-5015

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	:	03/16/2009

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