MEDICARE: VONS COMPANIES INC

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	PHY52295	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	2002300	OTHER		PK

General Provider Information

NPI Number	:	1437195211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VONS COMPANIES INC

Provider Business Mailing Address
First Line	:	250 E PARKCENTER BLVD
Second Line	:	MAILSTOP SEC 2-B
City	:	BOISE
State	:	ID
Zip	:	83706-3940
Country	:	US
Telephone Number	:	208-395-6200
Fax Number	:	623-282-3834

Provider Business Practice Location Address
First Line	:	33644 YUCAIPA BLVD
Second Line	:
City	:	YUCAIPA
State	:	CA
Zip	:	92399-2071
Country	:	US
Telephone Number	:	909-790-1961
Fax Number	:	909-797-9526

Authorized Official
Title or Position	:	THIRD PARTY MANAGER
Name	:	DEMOND HAWKINS
Credential	:	CPHT MBA
Telephone Number	:	208-395-3905

Provider Enumeration Date	:	06/21/2006
Last Update Date	:	07/19/2018

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Directions to “VONS COMPANIES INC ” Practice Location

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