Provider Demographics
NPI:1629229232
Name:WALGREEN CO.
Entity Type:Organization
Organization Name:WALGREEN CO.
Other - Org Name:WALGREENS #13119
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-554-8964
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MS 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 1:843 WAINEE ST
Practice Address - Street 2:SUITE 109
Practice Address - City:LAHAINA
Practice Address - State:HI
Practice Address - Zip Code:96761-1685
Practice Address - Country:US
Practice Address - Phone:808-661-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-10-02
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
HIPHY-760333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI62859701Medicaid
1240213OtherNCPDP
PHC049Medicare PIN
P00400633Medicare PIN
1240213OtherNCPDP