Provider Demographics
NPI:1457633570
Name:WALGREENS
Entity Type:Organization
Organization Name:WALGREENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-815-3373
Mailing Address - Street 1:3475 LISMORE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803
Mailing Address - Country:US
Mailing Address - Phone:863-815-3373
Mailing Address - Fax:863-815-5303
Practice Address - Street 1:6710 OLD POLK CITY RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809
Practice Address - Country:US
Practice Address - Phone:863-815-3373
Practice Address - Fax:863-815-5303
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34554305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service