Basic Information
| Provider Information | |||||||||
| NPI: | 1437195211 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VONS COMPANIES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VONS PHARMACY #1796 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 250 E PARKCENTER BLVD | ||||||||
| Address2: | MAILSTOP SEC 2-B | ||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083956200 | ||||||||
| FaxNumber: | 6232823834 | ||||||||
| Practice Location | |||||||||
| Address1: | 33644 YUCAIPA BLVD | ||||||||
| Address2: | |||||||||
| City: | YUCAIPA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923992071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097901961 | ||||||||
| FaxNumber: | 9097979526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | DEMOND | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | THIRD PARTY MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2083953905 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPHT MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHY52295 | CA | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1437195211 | 05 | CA | MEDICAID | 2002300 | 01 | PK | OTHER |