Provider Demographics
NPI:1942231741
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #1514
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MANAGED
Authorized Official - Middle Name:
Authorized Official - Last Name:CARE
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:925-467-2811
Mailing Address - Street 1:5918 STONERIDGE MALL RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-3229
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:925-467-2802
Practice Address - Street 1:13314 BOTHELL EVERETT HWY
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-5509
Practice Address - Country:US
Practice Address - Phone:425-337-4805
Practice Address - Fax:425-337-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF00005267333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4924634OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WA6015945Medicaid
4924634OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WAPHC015Medicare PIN
WAP00229889Medicare PIN