Provider Demographics
NPI:1659307429
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #1512
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:20427 N 27TH AVE # MS 4551
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3241
Mailing Address - Country:US
Mailing Address - Phone:623-869-3524
Mailing Address - Fax:623-869-1232
Practice Address - Street 1:4823 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6549
Practice Address - Country:US
Practice Address - Phone:775-823-2323
Practice Address - Fax:775-823-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPH1065332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV2816016Medicaid
2905822OtherOTHER ID NUMBER-COMMERCIAL NUMBER
NV0237520468Medicare NSC
NVPHC015Medicare PIN
NV2816016Medicaid