Provider Demographics
NPI:1932146487
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:OSCO 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 1:2610 S DOUGLAS HWY
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2610 S DOUGLAS HWY
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6468
Practice Address - Country:US
Practice Address - Phone:307-687-2996
Practice Address - Fax:307-686-6153
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WY52037143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5203714OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0483390904Medicare NSC