Healthcare Provider Details

I. General information

NPI: 1407894595
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16880 US HIGHWAY 441
MOUNT DORA FL
32757-6713
US

IV. Provider business mailing address

3030 CULLERTON ST
FRANKLIN PARK IL
60131-2205
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-0600
  • Fax: 352-735-0794
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 Number10428
License Number StateFL

VIII. Authorized Official

Name: DAN JOHNSON
Title or Position: MANAGER MANAGED HEALTHCARE
Credential:
Phone: 208-395-3436