Provider Demographics
NPI:1033124169
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREENS #11085
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-709-2351
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MS #790
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-709-2351
Mailing Address - Fax:217-709-2344
Practice Address - Street 1:52482 INDIANA STATE ROUTE 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3852
Practice Address - Country:US
Practice Address - Phone:574-271-0357
Practice Address - Fax:574-243-1516
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-29
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
IN60004192A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1529164OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IN100301210Medicaid
MI4825271 DMEMedicaid
IN100301210A DMEMedicaid
MI2861902Medicaid
IN100301210Medicaid
IN0282930327Medicare NSC
P00400633Medicare PIN