Provider Demographics
NPI:1437275518
Name:SAFEWAY PHARMACY
Entity Type:Organization
Organization Name:SAFEWAY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY TECH
Authorized Official - Prefix:
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:DIVELBISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-778-3098
Mailing Address - Street 1:4791 S JUNIPER LOOP RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-6160
Mailing Address - Country:US
Mailing Address - Phone:928-776-0286
Mailing Address - Fax:
Practice Address - Street 1:450 WHITE SPAR RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4626
Practice Address - Country:US
Practice Address - Phone:928-778-3098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3306183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty