Provider Demographics
NPI:1508307653
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:SAV-ON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR, HOST ADMIN & ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:DEMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3905
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:MAILSTOP SEC2-B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:208-395-3963
Mailing Address - Fax:623-336-6363
Practice Address - Street 1:250 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5906
Practice Address - Country:US
Practice Address - Phone:208-939-9850
Practice Address - Fax:208-939-2721
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS COMPANIES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-09
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
APPLIED FOROtherMNT BILLER