NPIMap

Organization Active NPI

Albertsons LLC

Doing business as Pavilions Pharmacy #4563

  • Community/Retail Pharmacy
  • San Clemente, CA
National Provider Identifier
1154377521
Registry record updated Aug 1, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community/Retail PharmacyTaxonomy code 3336C0003X
License
PHY51354 Issued in CA
Legal business name
ALBERTSONS LLC
Doing business as
Pavilions Pharmacy #4563
Practice address
989 Avenida Pico
San Clemente, CA 92673-3908
Phone
(949) 369-5596
Fax
(949) 369-5691
NPI assigned
May 26, 2006
Last updated
Aug 1, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 1, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Kathy Giannakopoulos
Title
Enrollment Manager
Phone
(208) 395-3954

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X NU
Community/Retail Pharmacy 3336C0003X PHY51354 CA Primary

Addresses

Primary practice location

989 Avenida Pico
San Clemente, CA 92673-3908

Mailing address

250 E Parkcenter Blvd
Boise, ID 83706-3940

Other identifiers 3

IdentifierTypeStateIssuer
071PHA477040MedicaidCA
071PHA457770MedicaidCA
2000502OtherPK

Other names 1

  • Pavilions Pharmacy #4563 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20130716000172 CA DME Supplier - PharmacyDME Supplier - Grocery Store 8729983515 Practice locations: San Clemente, CA

National Provider Directory

National Provider Directory
Tax ID family
Albertsons Inc 4103388 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 24

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 24

Member of 7

Organizations this organization is a member of, according to the National Provider Directory.

Locations

989 Avenida Pico
San Clemente, CA 92673
Phone (949) 369-5596

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148601600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1690848000000",
    "number": "1154377521",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "250 E PARKCENTER BLVD",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837063940"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "989 AVENIDA PICO",
            "city": "SAN CLEMENTE",
            "state": "CA",
            "postal_code": "926733908",
            "telephone_number": "949-369-5596",
            "fax_number": "949-369-5691"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ALBERTSONS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-26",
        "last_updated": "2023-08-01",
        "certification_date": "2023-08-01",
        "status": "A",
        "authorized_official_last_name": "GIANNAKOPOULOS",
        "authorized_official_first_name": "KATHY",
        "authorized_official_title_or_position": "ENROLLMENT MANAGER",
        "authorized_official_telephone_number": "208-395-3954"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "CA",
            "license": "PHY51354",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "071PHA477040",
            "state": "CA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "071PHA457770",
            "state": "CA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2000502",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pavilions Pharmacy #4563",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in San Clemente, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.