Provider Demographics
NPI:1881630408
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:DOMINICKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT MBA
Authorized Official - Phone:623-869-3778
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:
Mailing Address - Fax:
Practice Address - Street 1:2000 N RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-1419
Practice Address - Country:US
Practice Address - Phone:815-344-8340
Practice Address - Fax:815-344-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
IL333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Not Answered333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1456424OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL=========010Medicaid