Provider Demographics
NPI:1063881803
Name:STOP & SHOP SUPERMARKET COMPANY LLC
Entity type:Organization
Organization Name:STOP & SHOP SUPERMARKET COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:717-960-5666
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:ATTN: APRIL HOOVER
Mailing Address - City:CARLISLE
Mailing Address - State:PA
Mailing Address - Zip Code:17013-1607
Mailing Address - Country:US
Mailing Address - Phone:717-960-8553
Mailing Address - Fax:717-960-1389
Practice Address - Street 1:15601 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2746
Practice Address - Country:US
Practice Address - Phone:718-641-9853
Practice Address - Fax:718-738-6884
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHOLDUSA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-23
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034072OtherSTATE LICENSE
NYFT5740281OtherDEA LICENSE
NY0575340339Medicare NSC