Healthcare Provider Details

I. General information

NPI: 1447289400
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: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 MOUNT RUSHMORE RD
RAPID CITY SD
57701-4623
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 605-348-7552
  • Fax: 605-355-4559
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 Number100-1005
License Number StateSD

VII. Legacy identifiers

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

# 1
Identifier9162690
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier2094038
Identifier TypeOTHER
Identifier State
Identifier IssuerPK
# 3
Identifier8502590
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

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