1356614853 NPI number — WALGREEN CO

Table of content: (NPI 1356614853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356614853 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:
1356614853
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2024
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:
847-527-2489
Provider Business Mailing Address Fax Number:
217-709-2344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 STANHOPE ST
Provider Second Line Business Practice Location Address:
#23
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02116-5111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-375-7969
Provider Business Practice Location Address Fax Number:
617-375-9656
Provider Enumeration Date:
02/14/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PONCE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
847-527-2489

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: DS89805 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2243791 . This is a "NCPDP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 003128718 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110000108K , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03481069 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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