Provider Demographics
NPI:1316278690
Name:SAFEWAY INC
Entity type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANNAKOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3954
Mailing Address - Street 1:250 E PARKCENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13434 COLTON PL
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-5001
Practice Address - Country:US
Practice Address - Phone:503-655-4165
Practice Address - Fax:503-655-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
ORRP0002584CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500650352Medicaid
OR500619555Medicaid
2123809OtherPK
OR500650352Medicaid
0237520846Medicare NSC
P00229889Medicare PIN