Provider Demographics
NPI:1992996490
Name:WALGREEN CO
Entity type:Organization
Organization Name:WALGREEN CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR, VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-914-3154
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MAIL STOP #720
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-554-8494
Mailing Address - Fax:217-554-8546
Practice Address - Street 1:3545 W 86TH ST.
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1930
Practice Address - Country:US
Practice Address - Phone:608-833-0415
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-08
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
IN600004383A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1530840OtherNCPDP
IN100365790AMedicaid
IN100365790AMedicaid
IN0282931639Medicare NSC
P00400633Medicare PIN