Provider Demographics
NPI:1255670683
Name:SAVON PHARMACY
Entity Type:Organization
Organization Name:SAVON PHARMACY
Other - Org Name:NEW ALBERTSONS FORMERLY SUPERVALU
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELICKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:208-830-2453
Mailing Address - Street 1:660 S CLEARWATER LN APT 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-7746
Mailing Address - Country:US
Mailing Address - Phone:208-830-2453
Mailing Address - Fax:
Practice Address - Street 1:1653 S VISTA AVE
Practice Address - Street 2:PHARMACY
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3172
Practice Address - Country:US
Practice Address - Phone:208-331-3007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP66761835P0018X
NV176491835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Multi-Specialty