Provider Demographics
NPI:1003845066
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #0635
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MANAGED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:925-467-2806
Mailing Address - Street 1:5918 STONERIDGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:925-467-2802
Practice Address - Street 1:1295 W VICTORY WAY
Practice Address - Street 2:
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-2943
Practice Address - Country:US
Practice Address - Phone:970-824-8118
Practice Address - Fax:970-824-9517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0276332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0613263OtherOTHER ID NUMBER-COMMERCIAL NUMBER
P00229889OtherRAILROAD
CO03001369Medicaid
PHC015OtherFLU
P00229889OtherRAILROAD
0237520233Medicare NSC
COP00229889Medicare PIN