Healthcare Provider Details

I. General information

NPI: 1760411706
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: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4990 RIVER RD N
KEIZER OR
97303-4540
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 503-390-8819
  • Fax: 503-390-8822
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 TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0001487
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier269279
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier134937
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 3
Identifier2078484
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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