Provider Demographics
NPI:1336187418
Name:ALBERTSONS LLC
Entity type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER MANAGED HEALTHCARE
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-395-3436
Mailing Address - Street 1:75 REMITTANCE DR
Mailing Address - Street 2:SUITE 1119
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1590 US HIGHWAY 41 BYP S
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293-1033
Practice Address - Country:US
Practice Address - Phone:941-493-6340
Practice Address - Fax:941-497-6997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
FL77263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031459500Medicaid
1042047Medicare PIN
FL031459500Medicaid