Provider Demographics
NPI:1083996896
Name:WALGREEN
Entity type:Organization
Organization Name:WALGREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-745-8495
Mailing Address - Street 1:690 MATRIN LUTHER KINGS BLVD NORTH
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-1626
Mailing Address - Country:US
Mailing Address - Phone:248-745-8495
Mailing Address - Fax:248-745-8367
Practice Address - Street 1:690 MATRIN LUTHER KING BLVD N
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48342-1626
Practice Address - Country:US
Practice Address - Phone:248-745-8495
Practice Address - Fax:248-745-8367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302017458305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service