1417471863 NPI number — WALGREEN CO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417471863 NPI number — WALGREEN CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALGREEN CO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WALGREENS #18251
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417471863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 E VOORHEES ST
Provider Second Line Business Mailing Address:
MS 790
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61834-4509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-709-2351
Provider Business Mailing Address Fax Number:
217-709-2344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1422 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14103-9779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-798-1980
Provider Business Practice Location Address Fax Number:
585-798-1387
Provider Enumeration Date:
07/27/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
KIRA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
217-709-2351

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 036264 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5822932 . This is a "NCPDPD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 05040102 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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