Healthcare Provider Details

I. General information

NPI: 1760438782
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 BRIDGEPORT WAY W
UNIVERSITY PLACE WA
98466-4417
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 253-565-7997
  • Fax: 253-460-0440
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 NumberPHAR.CF.60342691
License Number StateWA

VIII. Authorized Official

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