MEDICARE: SAFEWAY 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	333600000X	Pharmacy	54013968	IL
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1469786	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1831128842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAFEWAY INC

Provider Business Mailing Address
First Line	:	20427 N 27TH AVE MSC 4501
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-3241
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3240 W ROOSEVELT RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4332
Country	:	US
Telephone Number	:	773-638-1399
Fax Number	:	773-638-1627

Authorized Official
Title or Position	:	MANAGED CARE ANALYST
Name	:	PATRICK HARRIS
Credential	:	CPHT MBA
Telephone Number	:	623-869-3778

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	05/15/2008

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Directions to “SAFEWAY INC ” Practice Location

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