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	333600000X	Pharmacy	PP410975L	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	3946879	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1396842167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHMARK STORES INC

Provider Business Mailing Address
First Line	:	200 MILIK ST
Second Line	:	M115
City	:	CARTERET
State	:	NJ
Zip	:	07008-1102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2506 KNIGHTS RD
Second Line	:
City	:	BENSALEM
State	:	PA
Zip	:	19020-3400
Country	:	US
Telephone Number	:	215-639-0100
Fax Number	:	215-639-3303

Authorized Official
Title or Position	:	ADMIN
Name	:	MINDI NORELLI
Credential	:
Telephone Number	:	732-499-3313

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	08/09/2007

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Directions to “PATHMARK STORES INC ” Practice Location

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