Provider Demographics
NPI:1942247614
Name:ALBERTSONS LLC
Entity type:Organization
Organization Name:ALBERTSONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NEW STORE ENROLLMENTS
Authorized Official - Prefix:MR
Authorized Official - First Name:LORENZO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:847-916-4463
Mailing Address - Street 1:26841 S TAMIAMI TRL
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-7817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26841 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-7817
Practice Address - Country:US
Practice Address - Phone:239-947-1922
Practice Address - Fax:239-947-3058
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBERTSONS HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-01
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
FLPH141953336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL031512500Medicaid
1078181OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL031512500Medicaid