Basic Information
Provider Information | |||||||||
NPI: | 1659528396 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WALGREEN CO | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WALGREENS #12107 | ||||||||
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: | 2177092351 | ||||||||
FaxNumber: | 2177092344 | ||||||||
Practice Location | |||||||||
Address1: | 400 S LIBERTY ST | ||||||||
Address2: |   | ||||||||
City: | WAYNESBORO | ||||||||
State: | GA | ||||||||
PostalCode: | 308301501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7064377977 | ||||||||
FaxNumber: | 7064377983 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/25/2008 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | KIRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2177092351 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | WALGREENS BOOTS ALLIANCE INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2022 |
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 | PHRE009525 | GA | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 942250904A | 05 | GA |   | MEDICAID | 942250904B | 01 | GA | MEDICAID DME | OTHER | 1157711 | 01 |   | NCPDP | OTHER |