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	3336C0003X	Community/Retail Pharmacy	Y04596	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0319928	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316986797
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	1849 W GREENWAY RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-3474
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1849 W GREENWAY RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-3474
Country	:	US
Telephone Number	:	602-866-0647
Fax Number	:	602-866-0674

Authorized Official
Title or Position	:	NEW STORE ENROLLMENTS
Name	:	MR. LORENZO TORRES III
Credential	:
Telephone Number	:	847-916-4463

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	12/12/2007

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Directions to “ALBERTSONS LLC ” Practice Location

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