Provider Demographics
NPI:1154604841
Name:WALLGREENS
Entity type:Organization
Organization Name:WALLGREENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:CONJA
Authorized Official - Middle Name:
Authorized Official - Last Name:SO-ROSILLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:650-637-9777
Mailing Address - Street 1:1414 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070
Mailing Address - Country:US
Mailing Address - Phone:650-637-9777
Mailing Address - Fax:650-637-1012
Practice Address - Street 1:1414 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-0000
Practice Address - Country:US
Practice Address - Phone:650-637-9777
Practice Address - Fax:650-637-1012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH52616261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health