Provider Demographics
NPI:1174079123
Name:SAFEWAY PHARMACY
Entity type:Organization
Organization Name:SAFEWAY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JORDYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:360-393-0912
Mailing Address - Street 1:3210 KINSROW AVE
Mailing Address - Street 2:APT 271
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-8864
Mailing Address - Country:US
Mailing Address - Phone:360-393-0912
Mailing Address - Fax:
Practice Address - Street 1:16300 SE EVELYN ST
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9515
Practice Address - Country:US
Practice Address - Phone:503-451-4009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015402333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy