Healthcare Provider Details

I. General information

NPI: 1982635793
Provider Name (Legal Business Name): SAFEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 06/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 NE 181ST ST
PORTLAND OR
97230-6721
US

IV. Provider business mailing address

5918 STONERIDGE MALL RD
PLEASANTON CA
94588-3229
US

V. Phone/Fax

Practice location:
  • Phone: 503-665-2565
  • Fax: 503-665-3307
Mailing address:
  • Phone: 925-467-2811
  • Fax: 925-467-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberRP-0001117
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier3810238
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER
# 2
Identifier008982
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: SUNNY YOST
Title or Position: MANAGED CARE PLAN SPECIALIST
Credential: CPHT
Phone: 925-467-2806