Provider Demographics
NPI:1972027696
Name:WALGREEN CO
Entity Type:Organization
Organization Name:WALGREEN CO
Other - Org Name:RITE AID #1618
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEETEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-709-2386
Mailing Address - Street 1:1901 E VOORHEES ST # MS 790
Mailing Address - Street 2:
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 1:100 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3266
Practice Address - Country:US
Practice Address - Phone:973-661-0900
Practice Address - Fax:973-661-1673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-03
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
NJ28RS00364600333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3153765OtherNCPDP
NJ0611069Medicaid
NJ28RS00364600OtherBOARD OF PHARMACY