NPIViewer - Provider NPI 1972560688

NPI:	1972560688
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:	217-709-2386
Mailing Address - Fax:	217-709-2344
Practice Address - Street 1:	130 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:	PITTSBURGH
Practice Address - State:	PA
Practice Address - Zip Code:	15275
Practice Address - Country:	US
Practice Address - Phone:	412-413-8000
Practice Address - Fax:	877-231-8302
EIN:	<UNAVAIL>
Is Organization Subpart?:	Yes
Parent Organization LBN:	WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:	<UNAVAIL>
Enumeration Date:	2006-04-27
Last Update Date:	2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:

State	License ID	Taxonomies
		332B00000X, 3336H0001X, 3336S0011X
PA	PP415372L	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
OH	0216524	Medicaid
ND	1482567	Medicaid
CA	1972560688	Medicaid
ID	1972560688	Medicaid
ME	1972560688	Medicaid
WV	6001307000	Medicaid
DC	81777100	Medicaid
NC	0395461	Medicaid
NM	12779024	Medicaid
MT	214642	Medicaid
DE	250622245	Medicaid
PA	001963828-0008	Medicaid
VT	1010753	Medicaid
AL	164561	Medicaid
MN	1972560688	Medicaid
KS	200333400A	Medicaid
NH	3102009	Medicaid
KY	7100162270	Medicaid
NV	100512960	Medicaid
WY	131971000	Medicaid
VA	1972560688	Medicaid
MO	1972560688	Medicaid
MD	4048229-00	Medicaid
RI	WA95680	Medicaid
CT	003135804	Medicaid
GA	003159944A	Medicaid
NJ	0039683	Medicaid
NE	10026155500	Medicaid
AK	1028415	Medicaid
	3974157	Other	NCPDP
CO	85885851	Medicaid
MA	110103221B	Medicaid
TN	3974157	Medicaid
OR	500603393	Medicaid
TX	580138	Medicaid
AZ	875403	Medicaid
NY	03904592	Medicaid
MS	04755357	Medicaid
WI	100002237	Medicaid
UT	1972560688	Medicaid
MI	1972560688	Medicaid
IA	1972560688	Medicaid
OK	200094500A	Medicaid
LA	2202847	Medicaid
WA	P11046424	Medicaid
AR	163032407	Medicaid
IN	200463010A	Medicaid
HI	779978	Medicaid
SC	7P372L	Medicaid