Provider Demographics
NPI:1730362617
Name:WALGREEN CO
Entity type:Organization
Organization Name:WALGREEN CO
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:847-527-2489
Mailing Address - Fax:217-709-2344
Practice Address - Street 1:330 N WABASH AVE STE 100
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2677
Practice Address - Country:US
Practice Address - Phone:765-664-2247
Practice Address - Fax:765-664-2328
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREENS BOOTS ALLIANCE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-13
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
IN60006116A333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200889010AMedicaid
1561895OtherNCPDP
KY7100240680Medicaid
PHC049Medicare PIN
IN0282936048Medicare NSC
1561895OtherNCPDP