MEDICARE: GREAT ATLANTIC & PACIFIC TEA COMPANY 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	023501	NY
3	333600000X	Pharmacy	023501	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	3332741	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1821013384
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT ATLANTIC & PACIFIC TEA COMPANY INC

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

Provider Business Practice Location Address
First Line	:	3105 E MAIN ST
Second Line	:
City	:	MOHEGAN LAKE
State	:	NY
Zip	:	10547-1521
Country	:	US
Telephone Number	:	914-526-0240
Fax Number	:	914-526-0244

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	:	10/06/2011

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