Provider Demographics
NPI:1407802424
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 MANAGER PLAN IMPLEMENTATION
Authorized Official - Prefix:
Authorized Official - First Name:DIONA
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWNSEND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4513
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:QUARRY B BLDG
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:208-395-3436
Mailing Address - Fax:208-495-4503
Practice Address - Street 1:475 W LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1707
Practice Address - Country:US
Practice Address - Phone:805-523-1441
Practice Address - Fax:805-523-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY513113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000500OtherPK
CA071PHA477480Medicaid
CA071PHA456920Medicaid
CA071PHA477480Medicaid