MEDICARE: WALGREENS PHARMACY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302R00000X	Health Maintenance Organization	16568	NV

General Provider Information

NPI Number	:	1164704326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREENS PHARMACY

Provider Business Mailing Address
First Line	:	6080 W GOWAN RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4816
Country	:	US
Telephone Number	:	702-648-2732
Fax Number	:	702-648-2509

Provider Business Practice Location Address
First Line	:	6101 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2660
Country	:	US
Telephone Number	:	702-648-2732
Fax Number	:	702-648-2509

Authorized Official
Title or Position	:	PHARMACIST
Name	:	MS. TANASORN FOWLER
Credential	:	PHD
Telephone Number	:	702-648-2732

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/14/2011

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Directions to “WALGREENS PHARMACY ” Practice Location

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