MEDICARE: FOOD BASICS 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	06238	NJ
3	333600000X	Pharmacy	06238	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	3135058	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	:	1336164995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOD BASICS INC

Provider Business Mailing Address
First Line	:	PO BOX 416369
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-6369
Country	:	US
Telephone Number	:	201-864-5617
Fax Number	:	201-864-5623

Provider Business Practice Location Address
First Line	:	1417 KENNEDY BLVD # 27
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-6307
Country	:	US
Telephone Number	:	201-864-5617
Fax Number	:	201-864-5623

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	:	10/11/2011

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Directions to “FOOD BASICS INC ” Practice Location

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