Provider Demographics
NPI:1740219757
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
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 MSC 4501
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 1:225 MAPLE AVE E
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4630
Practice Address - Country:US
Practice Address - Phone:703-281-0501
Practice Address - Fax:703-319-0194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA201002846333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8536201Medicaid
4825278OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA8536201Medicaid