Provider Demographics
NPI:1093752511
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:SAVON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST MGR, THIRD PARTY IMPLEMENTATIO
Authorized Official - Prefix:
Authorized Official - First Name:SUNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3920
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:
Mailing Address - Fax:
Practice Address - Street 1:2170 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3918
Practice Address - Country:US
Practice Address - Phone:727-441-8482
Practice Address - Fax:727-461-4386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FL50123336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031435800Medicaid
2008795OtherPK
0483390197Medicare NSC