WALGREENS SPECIALTY PHARMACY LLC

Provider Demographics

• NPI: 1942303110
• Name: WALGREENS SPECIALTY PHARMACY LLC
• Entity type: Organization
• Organization Name: WALGREENS SPECIALTY PHARMACY LLC
• Other - Org Name: <UNAVAIL>
• Authorized Official - Title/Position: MANAGER
• Authorized Official - First Name: JENNIFER
• Authorized Official - Last Name: PONCE
• 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: 41460 HAGGERTY CIR S
• Practice Address - City: CANTON
• Practice Address - State: MI
• Practice Address - Zip Code: 48188
• Practice Address - Country: US
• Practice Address - Phone: 888-282-5166
• Practice Address - Fax: 888-570-4700
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: WALGREENS BOOTS ALLIANCE INC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2006-09-06
• Last Update Date: 2024-12-04

Provider Licenses

State	License ID	Taxonomies
		332B00000X, 3336H0001X
MI	5301007754	3336S0011X, 333600000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	333600000X	Suppliers	Pharmacy
No	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies
No	3336H0001X	Suppliers	Pharmacy	Home Infusion Therapy Pharmacy
No	3336S0011X	Suppliers	Pharmacy	Specialty Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
VT	1023139	Medicaid
MO	1942303110	Medicaid
CO	9000182454	Medicaid
NV	003788101	Medicaid
ID	1942303110	Medicaid
PA	19638280007	Medicaid
WY	118687600	Medicaid
TN	2348046	Medicaid
MT	0213639	Medicaid
OH	0216482	Medicaid
KS	200333400D	Medicaid
	2348046	Other	NCPDP
IA	1942303110	Medicaid
MI	1942303110	Medicaid
UT	1942303110	Medicaid
MD	551206900	Medicaid
WI	100066062	Medicaid
MN	1942303110	Medicaid
WA	2008032	Medicaid
IN	201052500A	Medicaid
KY	7100151430	Medicaid
VT	1023139	Medicaid
WY	118687600	Medicaid
ID	1942303110	Medicaid
MO	1942303110	Medicaid
PA	19638280007	Medicaid
	2348046	Other	NCPDP
NV	003788101	Medicaid