Provider Demographics
NPI:1083650683
Name:NAI SATURN EASTERN LLC
Entity Type:Organization
Organization Name:NAI SATURN EASTERN LLC
Other - Org Name:SAFEWAY PHARMACY #2635
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT MANAGER, ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3906
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:MAILSTOP SEC2-B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:847-916-4463
Mailing Address - Fax:847-916-4736
Practice Address - Street 1:12821 BRAEMAR VILLAGE PLZ
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:VA
Practice Address - Zip Code:20136-5502
Practice Address - Country:US
Practice Address - Phone:703-257-0436
Practice Address - Fax:703-257-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010039563336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150047OtherPK
VA010042488Medicaid
2150047OtherPK