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	10428	FL

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	1061201	OTHER		NCPDP PROVIDER IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1407894595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	3030 CULLERTON ST
Second Line	:
City	:	FRANKLIN PARK
State	:	IL
Zip	:	60131-2205
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16880 US HIGHWAY 441
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-6713
Country	:	US
Telephone Number	:	352-383-0600
Fax Number	:	352-735-0794

Authorized Official
Title or Position	:	MANAGER MANAGED HEALTHCARE
Name	:	DAN JOHNSON
Credential	:
Telephone Number	:	208-395-3436

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	12/03/2010

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Directions to “ALBERTSONS LLC ” Practice Location

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