Provider Demographics
NPI:1316318744
Name:STOP AND SHOP SUPERMARKET CO LLC
Entity type:Organization
Organization Name:STOP AND SHOP SUPERMARKET CO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THIRD PARTY COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:717-960-8553
Mailing Address - Street 1:1149 HARRISBURG PIKE
Mailing Address - Street 2:ATTN: THIRD PARTY COORDINATOR
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 1:2136 BARTOW AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-4615
Practice Address - Country:US
Practice Address - Phone:718-320-2904
Practice Address - Fax:718-379-9565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AHOLDUSA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY034064OtherSTATE LICENSE
NYFS5770070OtherDEA LICENSE
NY0575340350Medicare NSC