MEDICARE: GRISTEDES FOODS 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	333600000X	Pharmacy	025444	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3327156	OTHER		NCPDP

General Provider Information

NPI Number	:	1396722864
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRISTEDES FOODS INC

Provider Business Mailing Address
First Line	:	549 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016
Country	:	US
Telephone Number	:	212-679-4000
Fax Number	:	212-679-4212

Provider Business Practice Location Address
First Line	:	549 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-3501
Country	:	US
Telephone Number	:	212-679-4000
Fax Number	:	212-679-4212

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. BARRY SHERMAN
Credential	:
Telephone Number	:	917-217-2789

Provider Enumeration Date	:	12/27/2005
Last Update Date	:	08/22/2020

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Directions to “GRISTEDES FOODS INC ” Practice Location

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