Provider Demographics
NPI:1104831361
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREENS #04191
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEETEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-709-2386
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:M/S 790
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-709-2386
Mailing Address - Fax:217-709-2344
Practice Address - Street 1:3445 TERRY RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-4956
Practice Address - Country:US
Practice Address - Phone:601-372-8750
Practice Address - Fax:
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:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MS0410401WJ333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330387Medicaid
2519176OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MS0282932146Medicare NSC
PHC049Medicare PIN
P00400633Medicare PIN