Basic Information
| Provider Information | |||||||||
| NPI: | 1003847823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAFEWAY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | SAFEWAY PHARMACY #0027 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 250 E PARKCENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083956200 | ||||||||
| FaxNumber: | 6233366896 | ||||||||
| Practice Location | |||||||||
| Address1: | 5025 S KIPLING PKWY | ||||||||
| Address2: | |||||||||
| City: | LITTLETON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039736795 | ||||||||
| FaxNumber: | 3039733918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/09/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIANNAKOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2083953954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PDO.0790000013 | CO | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 03765807 | 05 | CO | MEDICAID | 2001639 | 01 | PK | OTHER |