Provider Demographics
NPI:1831137256
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:SAVON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NEW STORE ENROLLMENTS
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4463
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:SUITE 1119
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 FLOWER MOUND RD
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75022-4819
Practice Address - Country:US
Practice Address - Phone:972-355-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-04
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX172853336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4598542OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TX463991Medicaid
4598542OtherOTHER ID NUMBER-COMMERCIAL NUMBER