MEDICARE: WALGREEN CO

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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	5301007519	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	2363579	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396750436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREEN CO

Provider Business Mailing Address
First Line	:	1901 E VOORHEES ST
Second Line	:	MAILSTOP #790
City	:	DANVILLE
State	:	IL
Zip	:	61834-4509
Country	:	US
Telephone Number	:	217-709-2386
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	13901 METROPOLITAN PKWY
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-3401
Country	:	US
Telephone Number	:	586-446-4699
Fax Number	:

Authorized Official
Title or Position	:	TREASURER
Name	:	MR. ALAN T NIELSEN
Credential	:
Telephone Number	:	847-315-3523

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	12/01/2015

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1346782836 — GINGER LONG
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Directions to “WALGREEN CO ” Practice Location

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