Healthcare Provider Details

I. General information

NPI: 1003842881
Provider Name (Legal Business Name): SAFEWAY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 ROOSEVELT AVE
ENUMCLAW WA
98022-8246
US

IV. Provider business mailing address

250 E PARKCENTER BLVD
BOISE ID
83706-3940
US

V. Phone/Fax

Practice location:
  • Phone: 360-802-1534
  • Fax: 360-802-5251
Mailing address:
  • Phone: 208-395-3963
  • Fax: 623-336-6896

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 NumberPHAR.CF.60515595
License Number StateWA

VII. Legacy identifiers

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

# 1
Identifier6020655
Identifier TypeMEDICAID
Identifier StateWA
Identifier Issuer
# 2
Identifier2110446
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

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