Provider Demographics
NPI:1568481596
Name:THE STOP & SHOP SUPERMARKET COMPANY, LLC
Entity type:Organization
Organization Name:THE STOP & SHOP SUPERMARKET COMPANY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-885-7454
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5005
Mailing Address - Country:US
Mailing Address - Phone:207-885-7454
Mailing Address - Fax:704-645-6531
Practice Address - Street 1:111 ROUTE 137
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-2153
Practice Address - Country:US
Practice Address - Phone:508-432-5001
Practice Address - Fax:508-432-5813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2114332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2231544OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MA0439673Medicaid
MA0439673Medicaid