WALGREENS SPECIALTY PHARMACY LLC

Provider Demographics

• NPI: 1669668752
• Name: WALGREENS SPECIALTY PHARMACY LLC
• Entity Type: Organization
• Organization Name: WALGREENS SPECIALTY PHARMACY LLC
• Other - Org Name: ALLIANCERX WALGREENS PRIME #12314
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: MANAGER
• Authorized Official - First Name: KIRA
• Authorized Official - Last Name: TAYLOR
• 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: 217-709-2386
• Mailing Address - Fax: 217-709-2344
• Practice Address - Street 1: 9775 SW GEMINI DR
• Practice Address - Street 2: STE 1
• Practice Address - City: BEAVERTON
• Practice Address - State: OR
• Practice Address - Zip Code: 97008
• Practice Address - Country: US
• Practice Address - Phone: 866-202-4014
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: WALGREENS BOOTS ALLIANCE INC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2007-09-21
• Last Update Date: 2021-05-11

Provider Licenses

State	License ID	Taxonomies
OR	RP-0002419	333600000X
		3336H0001X, 3336S0011X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	333600000X	Suppliers	Pharmacy
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy
No	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
UT	1669668752	Medicaid
MI	1669668752	Medicaid
	3842944	Other	NCPDP
TN	3842944	Medicaid
AK	1028445	Medicaid
WA	1092434	Medicaid
MT	1669668752	Medicaid
IA	1669668752	Medicaid
OR	278926	Medicaid
ND	457263	Medicaid
ID	1669668752	Medicaid
HI	685274-01	Medicaid
KY	7100277090	Medicaid
NM	37104811	Medicaid
MD	554205700	Medicaid
MN	1669668752	Medicaid
OK	200135400A	Medicaid
AZ	320618	Medicaid
CO	44039751	Medicaid
VA	1669668752	Medicaid
IN	200923000A	Medicaid
OH	0216467	Medicaid
PA	1021135430001	Medicaid
KS	200333400E	Medicaid
SC	7R2419	Medicaid
IN	200923000A	Medicaid
NH	3096653	Medicaid
NM	37104811	Medicaid
WA	1092434	Medicaid
MN	557965200	Medicaid
IL	361924025030	Medicaid
PA	1021135430001	Medicaid