Healthcare Provider Details

I. General information

NPI: 1134175789
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30901 RIVERSIDE DR
LAKE ELSINORE CA
92530-4934
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 951-245-5492
  • Fax: 951-245-8573
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberPHY51371
License Number StateCA

VIII. Authorized Official

Name: KATHY GIANNAKOPOULOS
Title or Position: ENROLLMENT MANAGER
Credential:
Phone: 208-395-3954