Provider Demographics
NPI:1942229976
Name:CARR-GOTTSTEIN FOODS CO
Entity Type:Organization
Organization Name:CARR-GOTTSTEIN FOODS CO
Other - Org Name:SAFEWAY PHARMACY #2728
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:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:MILE 1907 SEWARD HWY
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664-9800
Practice Address - Country:US
Practice Address - Phone:907-224-6960
Practice Address - Fax:907-224-6919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAFEWAY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-19
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK418332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0201664OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AKPH2050Medicaid
AKPH2050Medicaid
0201664OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AKP00229895Medicare PIN