Basic Information
| Provider Information | |||||||||
| NPI: | 1285861336 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALGREEN CO | ||||||||
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| OtherOrganizationName: | WALGREEN EASTERN CO #13775 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 E VOORHEES ST | ||||||||
| Address2: | M/S 790 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618344509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2175548494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100226222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5163528548 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2009 | ||||||||
| LastUpdateDate: | 06/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | CRAWFORD | ||||||||
| AuthorizedOfficialFirstName: | KERMIT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8479143154 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WALGREEN CO | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0002X | Y | Suppliers | Pharmacy | Clinic Pharmacy |
No ID Information.