Basic Information
| Provider Information | |||||||||
| NPI: | 1720093875 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALGREEN CO | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALGREENS #04687 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1901 E VOORHEES ST | ||||||||
| Address2: | MS790 | ||||||||
| City: | DANVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618344509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177092351 | ||||||||
| FaxNumber: | 2177092344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 ROUTE 112 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117633655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312079234 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 04/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | KIRA | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2177092351 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WALGREENS BOOTS ALLIANCE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 24453 | NY | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 02001536 | 05 | NY | MEDICAID | 3306227 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |