Healthcare Provider Details

I. General information

NPI: 1083643050
Provider Name (Legal Business Name): SAFEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13180 CICERO AVE
CRESTWOOD IL
60445-1470
US

IV. Provider business mailing address

20427 N 27TH AVE MSC 4501
PHOENIX AZ
85027-3241
US

V. Phone/Fax

Practice location:
  • Phone: 708-385-4810
  • Fax: 708-385-4653
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number54013028
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PATRICK HARRIS
Title or Position: MANAGED CARE ANALYST
Credential: CPHT MBA
Phone: 623-869-3778