MEDICARE: ALBERTSONS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy	PHY51322	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2062471	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114973773
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:	QUARRY B BLDG
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:	208-395-3436
Fax Number	:	208-495-4503

Provider Business Practice Location Address
First Line	:	18571 SOLEDAD CYN
Second Line	:
City	:	CANYON COUNTRY
State	:	CA
Zip	:	91351-3700
Country	:	US
Telephone Number	:	661-298-0233
Fax Number	:	661-298-4912

Authorized Official
Title or Position	:	ASST MANAGER PLAN IMPLEMENTATION
Name	:	DIONA TOWNSEND
Credential	:
Telephone Number	:	847-916-4513

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	07/19/2013

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Directions to “ALBERTSONS LLC ” Practice Location

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