1154352953 NPI number — NAI SATURN EASTERN LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154352953 NPI number — NAI SATURN EASTERN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NAI SATURN EASTERN LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SAFEWAY PHARMACY #1570
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154352953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 E PARKCENTER BLVD
Provider Second Line Business Mailing Address:
MAILSTOP SEC2-B
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-3940
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-916-4463
Provider Business Mailing Address Fax Number:
847-916-4736

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2304 HUNTERS WOODS PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-716-4203
Provider Business Practice Location Address Fax Number:
703-716-3285
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ELIOPULOS
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT MANAGER, ENROLLMENTS
Authorized Official Telephone Number:
208-395-3906

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0201003507 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8514658 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2150028 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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