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	1745	CT
2	332B00000X	Durable Medical Equipment & Medical Supplies	1745	CT
3	3336C0003X	Community/Retail Pharmacy	1745	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0718506	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295767168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STOP AND SHOP SUPERMARKET CO LLC

Provider Business Mailing Address
First Line	:	79 WASHINGTON AVE
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-1704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	79 WASHINGTON AVE
Second Line	:
City	:	NORTH HAVEN
State	:	CT
Zip	:	06473-1704
Country	:	US
Telephone Number	:	203-234-7461
Fax Number	:	203-234-7468

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	10/26/2011

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Directions to “STOP AND SHOP SUPERMARKET CO LLC ” Practice Location

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