MEDICARE: CARR-GOTTSTEIN FOODS CO

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	3336C0003X	Community/Retail Pharmacy	377	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1996884	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194754135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARR-GOTTSTEIN FOODS CO

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	:	301 N SANTA CLAUS LN
Second Line	:
City	:	NORTH POLE
State	:	AK
Zip	:	99705-6081
Country	:	US
Telephone Number	:	907-490-2760
Fax Number	:	907-490-2719

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

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	03/04/2020

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Directions to “CARR-GOTTSTEIN FOODS CO ” Practice Location

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