=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073551156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBERTSONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2006
-----------------------------------------------------
Last Update Date | 12/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 E CHEYENNE MTN BLVD
-----------------------------------------------------
City | COLORADO SPRINGS
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80906-4506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-576-4077
-----------------------------------------------------
Fax | 719-579-6700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 CULLERTON ST
-----------------------------------------------------
City | FRANKLIN PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60131-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASST MGR PLAN IMPLEMENTATION
-----------------------------------------------------
Name | DIONA TOWNSEND
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-916-4513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 240000002
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------