Provider Demographics
NPI:1760428379
Name:NAI SATURN EASTERN LLC
Entity Type:Organization
Organization Name:NAI SATURN EASTERN LLC
Other - Org Name:SAFEWAY PHARMACY #4872
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ENROLLMENTS MANAGER
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:847-916-4463
Mailing Address - Fax:847-916-4736
Practice Address - Street 1:6235 OXON HILL RD
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-3010
Practice Address - Country:US
Practice Address - Phone:301-839-0729
Practice Address - Fax:301-567-9072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MDP066453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149969OtherPK
MD214185000Medicaid
MD214185000Medicaid
P00229889Medicare PIN
PHC015Medicare PIN