Provider Demographics
NPI:1194919597
Name:WALGREEN EASTERN CO INC
Entity type:Organization
Organization Name:WALGREEN EASTERN CO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-709-2351
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MS 790
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-709-2351
Mailing Address - Fax:217-709-2344
Practice Address - Street 1:100 ROMANO VINEYARD WAY
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852
Practice Address - Country:US
Practice Address - Phone:401-295-5791
Practice Address - Fax:401-295-5872
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-29
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336M0003X
RIPHA00506333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4106971OtherNCPDP PROVIDER IDENTIFICATION NUMBER