Healthcare Provider Details

I. General information

NPI: 1205873759
Provider Name (Legal Business Name): ALBERTSONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5800 YELLOWSTONE RD
CHEYENNE WY
82009-4131
US

IV. Provider business mailing address

5800 YELLOWSTONE RD
CHEYENNE WY
82009-4131
US

V. Phone/Fax

Practice location:
  • Phone: 307-637-8361
  • Fax: 307-637-5959
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number5203396
License Number StateWY

VIII. Authorized Official

Name: LORENZO TORRES
Title or Position: NEW STORE ENROLLMENTS
Credential:
Phone: 847-916-4463