Healthcare Provider Details

I. General information

NPI: 1457366445
Provider Name (Legal Business Name): WALGREEN EASTERN CO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 SOUTH AVE
PLAINFIELD NJ
07062
US

IV. Provider business mailing address

1901 E VOORHEES ST MAILSTOP #790
DANVILLE IL
61834-4509
US

V. Phone/Fax

Practice location:
  • Phone: 908-757-7703
  • Fax: 908-757-2084
Mailing address:
  • Phone: 217-079-2351
  • Fax: 217-709-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberRS004522
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier4425103
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier3132305
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNCPDP

VIII. Authorized Official

Name: KIRA L TAYLOR
Title or Position: MANAGER
Credential:
Phone: 217-709-2351