Provider Demographics
NPI:1235176660
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:OSCO PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NEW STORE ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4463
Mailing Address - Street 1:855 OMAHA ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:855 OMAHA ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2655
Practice Address - Country:US
Practice Address - Phone:605-343-8542
Practice Address - Fax:605-341-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
SD963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4303626OtherOTHER ID NUMBER-COMMERCIAL NUMBER
4303626OtherOTHER ID NUMBER
SD8502520Medicaid
4303626OtherOTHER ID NUMBER