Provider Demographics
NPI:1982635793
Name:SAFEWAY INC
Entity Type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:SAFEWAY PHARMACY #1269
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SUNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:YOST
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:925-467-2806
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:925-467-2811
Mailing Address - Fax:925-467-2802
Practice Address - Street 1:1541 NE 181ST ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-6721
Practice Address - Country:US
Practice Address - Phone:503-665-2565
Practice Address - Fax:503-665-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0001117332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810238OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OR008982Medicaid
OR0237520170Medicare NSC
ORPHC015Medicare PIN
OR008982Medicaid