Provider Demographics
NPI:1689047862
Name:NAI SATURN EASTERN LLC
Entity Type:Organization
Organization Name:NAI SATURN EASTERN LLC
Other - Org Name:SAFEWAY PHARMACY #3274
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENT MGR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNAKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3954
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:208-395-3920
Mailing Address - Fax:623-282-3834
Practice Address - Street 1:3702 EAST-WEST HIGHWAY
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-2013
Practice Address - Country:US
Practice Address - Phone:301-955-1943
Practice Address - Fax:301-955-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MDP069573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2155212OtherPK
MD874071200Medicaid
2155212OtherPK