MEDICARE: VONS COMPANIES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY52362	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1990697	OTHER		PK

General Provider Information

NPI Number	:	1538191366
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VONS COMPANIES INC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:	MAILSTOP SEC 2-B
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:	208-395-6200
Fax Number	:	623-282-3834

Provider Business Practice Location Address
First Line	:	4226 WOODRUFF AVE
Second Line	:
City	:	LAKEWOOD
State	:	CA
Zip	:	90713-3143
Country	:	US
Telephone Number	:	562-496-4155
Fax Number	:	562-496-4145

Authorized Official
Title or Position	:	THIRD PARTY MANAGER
Name	:	DEMOND HAWKINS
Credential	:
Telephone Number	:	208-395-3905

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/19/2018

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