Healthcare Provider Details

I. General information

NPI: 1053792382
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2015
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 CASITAS PASS RD
CARPINTERIA CA
93013
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 805-684-8367
  • Fax: 805-684-8848
Mailing address:
  • Phone: 208-395-3905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number43276
License Number StateCA

VIII. Authorized Official

Name: DEMOND HAWKINS
Title or Position: MGR, PHARMACY ENROLLMENTS
Credential:
Phone: 208-395-3905