Provider Demographics
NPI:1629169289
Name:JEWEL OSCO SOUTHWEST LLC
Entity type:Organization
Organization Name:JEWEL OSCO SOUTHWEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY ENROLLMENT SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3963
Mailing Address - Street 1:75 REMITTANCE DRIVE
Mailing Address - Street 2:SUITE 1242
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1242
Mailing Address - Country:US
Mailing Address - Phone:847-916-4463
Mailing Address - Fax:847-916-4736
Practice Address - Street 1:250 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3940
Practice Address - Country:US
Practice Address - Phone:208-395-3963
Practice Address - Fax:623-336-6363
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00447103OtherRAILROAD MEDICARE TPAN
PHC034Medicare PIN
P00447103Medicare PIN