MEDICARE: THE STOP & SHOP SUPERMARKET COMPANY, 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	332B00000X	Durable Medical Equipment & Medical Supplies	027124	NY
2	333600000X	Pharmacy	027124	NY
3	3336C0003X	Community/Retail Pharmacy	027124	NY

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	3342235	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1750313615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE STOP & SHOP SUPERMARKET COMPANY, LLC

Provider Business Mailing Address
First Line	:	25 WATERFRONT PL
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-6001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 WATERFRONT PL
Second Line	:
City	:	PORT CHESTER
State	:	NY
Zip	:	10573-6001
Country	:	US
Telephone Number	:	914-937-7452
Fax Number	:	914-937-7894

Authorized Official
Title or Position	:	PRESIDENT OF PHARMACY
Name	:	ROGER WHEELER
Credential	:
Telephone Number	:	207-885-2518

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	04/09/2025

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