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	PH17746	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1059395	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	1059395	OTHER		OTHER ID NUMBER

General Provider Information

NPI Number	:	1700823234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	4407 NORTHLAKE BLVD
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6255
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4407 NORTHLAKE BLVD
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33410-6255
Country	:	US
Telephone Number	:	561-622-2813
Fax Number	:	561-622-3698

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	11/21/2007

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Directions to “ALBERTSONS LLC ” Practice Location

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