NPIViewer - Provider NPI 1851463087

NPI:	1851463087
Name:	WALGREENS SPECIALTY PHARMACY LLC
Entity type:	Organization
Organization Name:	WALGREENS SPECIALTY PHARMACY LLC
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:	10530 JOHN W ELLIOTT DR
Practice Address - Street 2:	STE 100
Practice Address - City:	FRISCO
Practice Address - State:	TX
Practice Address - Zip Code:	75033
Practice Address - Country:	US
Practice Address - Phone:	800-424-9002
Practice Address - Fax:	800-874-9179
EIN:	<UNAVAIL>
Is Organization Subpart?:	Yes
Parent Organization LBN:	WALGREENS BOOTS ALLIANCE
Parent Organization TIN:	<UNAVAIL>
Enumeration Date:	2006-11-14
Last Update Date:	2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
		332B00000X, 3336H0001X
TX	14412	3336S0011X, 333600000X

Primary?	Code	Type	Classification	Specialization
Yes	333600000X	Suppliers	Pharmacy
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy
No	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

State	Identifier ID	ID Type	Issuer
WY	119788601	Medicaid
OK	200037560A	Medicaid
IA	1851463087	Medicaid
NH	3124086	Medicaid
AZ	498604	Medicaid
SD	1851463087	Medicaid
VA	1851463087	Medicaid
MN	1851463087	Medicaid
IN	200390000A	Medicaid
LA	2204947	Medicaid
SC	7T4412	Medicaid
TN	491055	Medicaid
NM	96722339	Medicaid
ID	1851463087	Medicaid
WA	2013289	Medicaid
TX	466694	Medicaid
NV	1851463087	Medicaid
MI	1851463087	Medicaid
AR	185350407	Medicaid
MD	554204900	Medicaid
KY	7100151520	Medicaid
PA	00196328280006	Medicaid
UT	1851463087	Medicaid
	4591055	Other	NCPDP
OR	500638341	Medicaid
HI	007571	Medicaid
OH	0216495	Medicaid
MS	07033855	Medicaid
AK	1028472	Medicaid
MT	1851463087	Medicaid
KY	7100151520	Medicaid