Provider Demographics
NPI:1053557801
Name:SAFEWAY INC
Entity type:Organization
Organization Name:SAFEWAY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGED CARE PLAN SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-869-3524
Mailing Address - Street 1:20427 N 27TH AVE # MS 4551
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-3241
Mailing Address - Country:US
Mailing Address - Phone:623-869-3524
Mailing Address - Fax:623-869-1232
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2045
Practice Address - Country:US
Practice Address - Phone:541-266-7542
Practice Address - Fax:541-266-7638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR3843441OtherNCPDP
OR1053557801Medicaid
OR1053557801Medicaid
0237520848Medicare NSC
P00229889Medicare PIN