Provider Demographics
NPI:1497924708
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREENS #10989
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:
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 1:2431 BOSTON RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-9067
Practice Address - Country:US
Practice Address - Phone:718-652-0492
Practice Address - Fax:718-654-2596
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-21
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
NY0293073336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03091334Medicaid
NY3357464OtherNCPDP
NY3357464OtherNCPDP