Provider Demographics
NPI:1104855154
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #0353
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:20427 N 27TH AVE # MSC4551
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 1:3285 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4535
Practice Address - Country:US
Practice Address - Phone:503-361-3346
Practice Address - Fax:503-361-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR001748332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3813777OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OR170389Medicaid
OR0237520565Medicare NSC
OR170389Medicaid
ORPHC015Medicare PIN