1063428498 NPI number — WALGREEN CO

Table of content: (NPI 1063428498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063428498 NPI number — WALGREEN CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALGREEN CO
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:
6
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:
1063428498
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 E VOORHEES ST
Provider Second Line Business Mailing Address:
MS 790
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61834-4509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-709-2351
Provider Business Mailing Address Fax Number:
217-709-2344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
INTER CARR 2 PR-122
Provider Second Line Business Practice Location Address:
AVE FENWAL
Provider Business Practice Location Address City Name:
SAN GERMAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00683-4476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-892-4482
Provider Business Practice Location Address Fax Number:
787-892-4400
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
KIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
217-709-2351

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 05F2211 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4024206 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 012184200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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