Provider Demographics
NPI:1497762439
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREEN DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-554-8964
Mailing Address - Street 1:20145 VAN AKEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-3618
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20145 VAN AKEN BLVD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-3618
Practice Address - Country:US
Practice Address - Phone:216-921-6042
Practice Address - Fax:216-921-3677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21555100333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered333600000XSuppliersPharmacy
Not Answered3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2610295Medicaid
3673995OtherOTHER ID NUMBER-COMMERCIAL NUMBER