Organization
WALDBAUM INC
Active
Parent organization
THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Other names
WALDBAUMS PHARMACY
Organization subpart
Yes
Provider details
NPI number
Legal business name
THE GREAT ATLANTIC AND PACIFIC TEA COMPANY INC
Authorized official
SUSAN KIJOWSKI (PHARMACY SPECIALIST)
(201) 571-8326
Entity
Organization
Contact information
Practice address
4343 AMBOY RD, STATEN ISLAND, NY 10312-3819
(718) 984-6073
(718) 984-5634
Mailing address
4343 AMBOY RD, STATEN ISLAND, NY 10312-3819
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
025266
NY
333600000X
Pharmacy
Primary
025266
NY
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02248199
—
NY
01
—
022481990442
MEDICAID DME
NY
01
—
3324174
OTHER ID NUMBER-COMMERCIAL NUMBER
—
Enumeration date
07/13/2006
Last updated
11/09/2007
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