Provider Demographics
NPI:1194740654
Name:GREAT ATLANTIC & PACIFIC TEA COMPANY INC
Entity type:Organization
Organization Name:GREAT ATLANTIC & PACIFIC TEA COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER, REGULATORY COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIJOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-571-8326
Mailing Address - Street 1:PO BOX 416369
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2005 ALBANY POST RD
Practice Address - Street 2:
Practice Address - City:CROTON ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10520-1573
Practice Address - Country:US
Practice Address - Phone:914-271-0832
Practice Address - Fax:914-271-0993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025546332B00000X, 333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY023549470442OtherMEDICAID DME
3328588OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NY02354947Medicaid
3328588OtherOTHER ID NUMBER-COMMERCIAL NUMBER