Provider Demographics
NPI:1063458693
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:DOMINICKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT MBA
Authorized Official - Phone:623-869-3778
Mailing Address - Street 1:20427 N 27TH AVE MSC 4501
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8847 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-1907
Practice Address - Country:US
Practice Address - Phone:708-598-4013
Practice Address - Fax:708-598-4187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL54013917333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1469053OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1469053OtherOTHER ID NUMBER-COMMERCIAL NUMBER