Provider Demographics
NPI:1417192766
Name:WALGREEN CO
Entity type:Organization
Organization Name:WALGREEN CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-527-2489
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:847-527-2489
Mailing Address - Fax:217-709-2344
Practice Address - Street 1:4910 POPLAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-1685
Practice Address - Country:US
Practice Address - Phone:601-483-3997
Practice Address - Fax:601-483-9872
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-15
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0002X
MS07969/01.2333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01128896Medicaid
MS07777228OtherMEDICAID DME
MS2587559OtherNCPDP
MS2587559OtherNCPDP
MS01128896Medicaid
MSPHC049Medicare PIN