Healthcare Provider Details

I. General information

NPI: 1205919610
Provider Name (Legal Business Name): WALGREEN CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 N CENTRAL AVE
HUMBOLDT TN
38343-1753
US

IV. Provider business mailing address

1901 E VOORHEES ST # MS 790
DANVILLE IL
61834-4515
US

V. Phone/Fax

Practice location:
  • Phone: 731-784-2613
  • Fax: 731-784-7410
Mailing address:
  • Phone: 847-527-2489
  • Fax: 217-709-2344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number2132
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number0000002132
License Number StateTN

VII. Legacy identifiers

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

# 1
Identifier9449858
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer
# 2
Identifier4427856
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER
# 3
Identifier1532437
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerMEDICAID-DME
# 4
Identifier3914212
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerMEDICARE FLU

VIII. Authorized Official

Name: JENNIFER PONCE
Title or Position: MANAGER
Credential:
Phone: 847-527-2489