Provider Demographics
NPI:1639253776
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:WALGREENS #15780
Other - Org Type:Doing Business As
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 1:5115 S PEORIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-5620
Practice Address - Country:US
Practice Address - Phone:918-749-4601
Practice Address - Fax:918-748-0467
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-25
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24825332B00000X
OK23137333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236540OMedicaid
OK400522489OtherMEDICARE FLU
OK100241490ZOtherMEDICAID DME
3716365OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0448880005Medicare NSC
OK100236540OMedicaid