MEDICARE: GRISTEDES OPERATING CORP

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	183500000X	Pharmacist	024383	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
3	3347829	OTHER		NCPDP

General Provider Information

NPI Number	:	1871570853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRISTEDES OPERATING CORP

Provider Business Mailing Address
First Line	:	460 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-6027
Country	:	US
Telephone Number	:	212-251-0052
Fax Number	:	212-251-0058

Provider Business Practice Location Address
First Line	:	460 3RD AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10016-6027
Country	:	US
Telephone Number	:	212-251-0052
Fax Number	:	212-251-0058

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	12/23/2008

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Directions to “GRISTEDES OPERATING CORP ” Practice Location

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