Basic Information
Provider Information | |||||||||
NPI: | 1548562481 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALGREEN CO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MICHELIN FAMILY HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1901 E VOORHEES ST | ||||||||
Address2: | MS 790 | ||||||||
City: | DANVILLE | ||||||||
State: | IL | ||||||||
PostalCode: | 618344509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2177092386 | ||||||||
FaxNumber: | 2177092344 | ||||||||
Practice Location | |||||||||
Address1: | ONE PARKWAY SOUTH STE E | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296155022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644586933 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/29/2010 | ||||||||
LastUpdateDate: | 09/27/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SWEETEN | ||||||||
AuthorizedOfficialFirstName: | ALYSSA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2177092386 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WALGREENS BOOTS ALLIANCE INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X |   |   | Y |   | Suppliers | Pharmacy |   |
No ID Information.