Healthcare Provider Details

I. General information

NPI: 1255387627
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S BLUFF ST
ST GEORGE UT
84770-5202
US

IV. Provider business mailing address

250 E PARKCENTER BLVD QUARRY B BLDG
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 435-628-0469
  • Fax: 435-688-2808
Mailing address:
  • Phone: 208-395-3436
  • Fax: 208-495-4503

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 TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8600197-1703
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier204057706019
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier2100107
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: DIONA TOWNSEND
Title or Position: ASST MANAGER PLAN IMPLEMENTATION
Credential:
Phone: 847-916-4513