Healthcare Provider Details

I. General information

NPI: 1134498942
Provider Name (Legal Business Name): WALGREENS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W STATE ST
TRENTON OH
45067-1585
US

IV. Provider business mailing address

1663 OLD STATE ROUTE 122
LEBANON OH
45036-9499
US

V. Phone/Fax

Practice location:
  • Phone: 513-737-3504
  • Fax:
Mailing address:
  • Phone: 937-478-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number03315609
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number03315609
License Number StateOH

VIII. Authorized Official

Name: MR. MARK STEPHEN MCCALL
Title or Position: PHARMACIST
Credential:
Phone: 937-478-5506