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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY55405	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2163650	OTHER		PK

General Provider Information

NPI Number	:	1124572631
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1910 N CAMPUS AVE
Second Line	:
City	:	UPLAND
State	:	CA
Zip	:	91784-1667
Country	:	US
Telephone Number	:	909-946-3340
Fax Number	:	909-946-0052

Authorized Official
Title or Position	:	ENROLLMENT MANAGER
Name	:	KATHY GIANNAKOPOULOS
Credential	:
Telephone Number	:	208-395-3954

Provider Enumeration Date	:	08/12/2016
Last Update Date	:	04/03/2020

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Directions to “ALBERTSONS LLC ” Practice Location

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