Provider Demographics
NPI:1982642344
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:SAVON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER MANAGED HEALTHCARE
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3436
Mailing Address - Street 1:3030 CULLERTON ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60131-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3046 LAVON DR
Practice Address - Street 2:SUITE 129
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75040-8794
Practice Address - Country:US
Practice Address - Phone:972-414-8028
Practice Address - Fax:972-530-4561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX148293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4585103OtherNCPDP PROVIDER IDENTIFICATION NUMBER
TX463392Medicaid
0483390368Medicare NSC