MEDICARE: WALGREEN CO

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy	54013352	IL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1467263	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

NPI Number	:	1144235300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREEN CO

Provider Business Mailing Address
First Line	:	1901 E VOORHEES ST
Second Line	:	MS 790
City	:	DANVILLE
State	:	IL
Zip	:	61834-4515
Country	:	US
Telephone Number	:	847-527-2489
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	2945 S 6TH ST
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62703-4024
Country	:	US
Telephone Number	:	217-788-5846
Fax Number	:	217-788-8128

Authorized Official
Title or Position	:	MANAGER
Name	:	JENNIFER PONCE
Credential	:
Telephone Number	:	847-527-2489

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	10/01/2025

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039