Provider Demographics
NPI:1114932464
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREENS #09493
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 1:2351 S TOWNSEND AVE
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-5438
Practice Address - Country:US
Practice Address - Phone:970-252-1743
Practice Address - Fax:970-252-3785
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:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
CO648333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0619835OtherOTHER ID NUMBER-COMMERCIAL NUMBER
WY124114100Medicaid
CO53055233Medicaid
WY124114100Medicaid
P00400633Medicare PIN
WY124114100Medicaid
0619835OtherOTHER ID NUMBER-COMMERCIAL NUMBER