Provider Demographics
NPI:1285733253
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:
Practice Address - Street 1:2110 RT 130
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:NJ
Practice Address - Zip Code:08010
Practice Address - Country:US
Practice Address - Phone:609-871-1550
Practice Address - Fax:609-877-7719
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GREAT ATLANTIC & PACIFIC TEA CO INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-22
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRS02202333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3102720OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NJ4291409Medicaid
NJ4291409Medicaid