Provider Demographics
NPI:1457880940
Name:ALBERTSONS LLC
Entity Type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:ALBERTSONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST MGR, PHARMACY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIOPULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3906
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:208-395-3963
Mailing Address - Fax:623-336-6363
Practice Address - Street 1:1219 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-433-9905
Practice Address - Fax:208-433-9907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS COMPANIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-08
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20011403OtherNORIDIAN PROVIDER NO