1134134323 NPI number — WALGREEN EASTERN CO INC

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 1134134323 NPI number — WALGREEN EASTERN CO INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALGREEN EASTERN CO INC
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:
1134134323
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2023
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:
MAILSTOP #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:
35 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEABODY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01960-5548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-977-9211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2006

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: 333600000X , with the licence number: 1744 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 110000110P , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2229412 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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