Provider Demographics
NPI:1003852864
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #2004
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNAKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3954
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3540 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5329
Practice Address - Country:US
Practice Address - Phone:505-564-3086
Practice Address - Fax:505-564-3089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
NMPH000038683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0000N1393Medicaid
2058856OtherPK
2058856OtherPK
0237520692Medicare NSC
P00229889Medicare PIN