Provider Demographics
NPI:1174620934
Name:PATHMARK STORES INC
Entity type:Organization
Organization Name:PATHMARK STORES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:2 PARAGON DR
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1718
Mailing Address - Country:US
Mailing Address - Phone:201-573-9700
Mailing Address - Fax:201-571-8335
Practice Address - Street 1:498 E 30TH ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-2133
Practice Address - Country:US
Practice Address - Phone:973-278-9339
Practice Address - Fax:973-278-0199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS2800325300332B00000X
3336C0003X
NJRS004557333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4534204Medicaid
3132595OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3132595OtherOTHER ID NUMBER-COMMERCIAL NUMBER