Basic Information
| Provider Information | |||||||||
| NPI: | 1003862533 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHAWS SUPERMARKETS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OSCO PHARMACY #2585 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 E PARKCENTER BLVD | ||||||||
| Address2: | MAILSTOP SEC2-B | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083956200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2260 STATE RD | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088338819 | ||||||||
| FaxNumber: | 5088332756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELIOPULOS | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT ASSISTANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2083953906 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | DS3070 | MA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 110000003G | 05 | MA | MEDICAID | 2037756 | 01 | PK | OTHER |