Provider Demographics
NPI:1770529398
Name:SAFEWAY INC
Entity type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:CPHT
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:20427 N 27TH AVE # MSC4551
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5111 WESTFIELDS BLVD
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20120-4365
Practice Address - Country:US
Practice Address - Phone:703-631-5292
Practice Address - Fax:703-502-0687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2008-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA201002630333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8530335Medicaid
4823515OtherOTHER ID NUMBER-COMMERCIAL NUMBER
VA0237520093Medicare NSC
VAPHC015Medicare PIN
VAP00229889Medicare PIN