Provider Demographics
NPI:1578891016
Name:WALGREENS PHARMACY
Entity Type:Organization
Organization Name:WALGREENS PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:N
Authorized Official - Last Name:FANT
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:903-792-8918
Mailing Address - Street 1:4415 N STATELINE AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3138
Mailing Address - Country:US
Mailing Address - Phone:903-795-8918
Mailing Address - Fax:903-792-6198
Practice Address - Street 1:4415 N STATELINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3138
Practice Address - Country:US
Practice Address - Phone:903-795-8918
Practice Address - Fax:903-792-6198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183500000XMedicaid