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	PH13708	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1076872	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1861439531
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBERTSONS LLC

Provider Business Mailing Address
First Line	:	1295 S MISSOURI AVE
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33756-4174
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1295 S MISSOURI AVE
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33756-4174
Country	:	US
Telephone Number	:	727-449-1704
Fax Number	:	727-462-9771

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

Provider Enumeration Date	:	06/01/2006
Last Update Date	:	11/26/2007

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