Basic Information
| Provider Information | |||||||||
| NPI: | 1962548826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WALGREEN CO. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WALGREENS #10845 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 2301 HOLMES ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164712072 | ||||||||
| FaxNumber: | 8164717123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BADGLEY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8473153012 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WALGREENS BOOTS ALLIANCE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/14/2022 | ||||||||
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 | 2007002523 | MO | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2637316 | 01 | NCPDP | OTHER | 100432190R | 05 | KS | MEDICAID | 6263030002 | 05 | MO | MEDICAID | 100432190S | 05 | KS | MEDICAID | 606303006 | 05 | MO | MEDICAID |