1023455383 NPI number — WALGREENS 11079

Table of content: NATHAN RYAN EHRMENTROUT RD (NPI 1831084300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023455383 NPI number — WALGREENS 11079

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALGREENS 11079
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:
Provider Other Organization Name Type Code:
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:
1023455383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/28/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 WILMOT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEERFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60015-4620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-366-0335
Provider Business Mailing Address Fax Number:
302-453-3168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
38627 BENRO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELMAR
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19940-3572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-907-1010
Provider Business Practice Location Address Fax Number:
302-907-1006
Provider Enumeration Date:
05/28/2013

Additional Information

Authorized Official

Authorized Official Last Name:
REITZ
Authorized Official First Name:
JON
Authorized Official Middle Name:
Authorized Official Title or Position:
MARKET PHARMACY DIRECTOR
Authorized Official Telephone Number:
302-366-0335

Provider Taxonomy Codes

  • Taxonomy code: 261QC1500X , with the licence number:  380101061159913 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com