Provider Demographics
NPI:1558376681
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:CORPORATE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUONKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:847-914-3154
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MAILSTOP #720
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-554-8964
Mailing Address - Fax:217-554-8546
Practice Address - Street 1:14301 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2303
Practice Address - Country:US
Practice Address - Phone:313-371-2450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-29
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MI5301007142333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4808539 DMEMedicaid
2360826OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI4168950Medicaid
MI4168950Medicaid
P0040063Medicare PIN
MI0282932728Medicare NSC