Provider Demographics
NPI:1184100513
Name:WALGREENS 1261-2
Entity type:Organization
Organization Name:WALGREENS 1261-2
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:DAGHER
Authorized Official - Suffix:
Authorized Official - Credentials:BSPHARM
Authorized Official - Phone:407-345-7155
Mailing Address - Street 1:8325 SOUTHPARK CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-9075
Mailing Address - Country:US
Mailing Address - Phone:407-345-7155
Mailing Address - Fax:
Practice Address - Street 1:8325 SOUTHPARK CIR STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-9075
Practice Address - Country:US
Practice Address - Phone:407-345-7155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26812333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26812OtherFL BOARD OF PHARMACY LICENSE