Basic Information
| Provider Information | |||||||||
| NPI: | 1922046341 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALBERTSONS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAVON PHARMACY #4105 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 E PARKCENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837063940 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4625 FRANKFORD RD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752877108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727326863 | ||||||||
| FaxNumber: | 9727327564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | GIANNAKOPOULOS | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2083953954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 15337 | TX | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 463508 | 05 | TX | MEDICAID | 2100803 | 01 | PK | OTHER |