MEDICARE: WALGREEN EASTERN CO INC

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	204	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4105727	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821003997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREEN EASTERN CO INC

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	:	847-527-2489
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	1074 MINERAL SPRING AVE
Second Line	:
City	:	NORTH PROVIDENCE
State	:	RI
Zip	:	02904-4104
Country	:	US
Telephone Number	:	401-725-6824
Fax Number	:

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

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	09/10/2024

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Directions to “WALGREEN EASTERN CO INC ” Practice Location

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