Provider Demographics
NPI:1821034430
Name:VONS COMPANIES INC
Entity Type:Organization
Organization Name:VONS COMPANIES INC
Other - Org Name:VONS PHARMACY #1734
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT MBA
Authorized Official - Phone:208-395-3905
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:MAILSTOP SEC 2-B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:208-395-6200
Mailing Address - Fax:623-282-3834
Practice Address - Street 1:522 ORANGE ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-3208
Practice Address - Country:US
Practice Address - Phone:909-748-7788
Practice Address - Fax:909-748-7738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY523613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1996394OtherPK
CA1821034430Medicaid
PHC021Medicare PIN
1115530174Medicare NSC
P00229894Medicare PIN