Provider Demographics
NPI:1023455383
Name:WALGREENS 11079
Entity type:Organization
Organization Name:WALGREENS 11079
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET PHARMACY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:REITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-366-0335
Mailing Address - Street 1:200 WILMOT RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-4620
Mailing Address - Country:US
Mailing Address - Phone:302-366-0335
Mailing Address - Fax:302-453-3168
Practice Address - Street 1:38627 BENRO DR
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:DE
Practice Address - Zip Code:19940-3572
Practice Address - Country:US
Practice Address - Phone:302-907-1010
Practice Address - Fax:302-907-1006
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO./ILL.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE380101061159913261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health