Healthcare Provider Details

I. General information

NPI: 1669428223
Provider Name (Legal Business Name): SHAWS SUPERMARKETS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1377 HYDE PARK AVE
HYDE PARK MA
02136
US

IV. Provider business mailing address

250 E PARKCENTER BLVD MAILSTOP SEC2-B
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 617-364-3161
  • Fax: 617-361-3417
Mailing address:
  • Phone: 208-395-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberDS3239
License Number StateMA

VIII. Authorized Official

Name: KATHY GIANNAKOPOULOS
Title or Position: ENROLLMENT MANAGER
Credential:
Phone: 208-395-3932