=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184100513
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREENS 1261-2
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8325 SOUTHPARK CIR STE 200
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-9075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-345-7155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8325 SOUTHPARK CIR STE 200
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32819-9075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-345-7155
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST-IN-CHARGE
-----------------------------------------------------
Name | WANDA ANNETTE DAGHER
-----------------------------------------------------
Credential | BSPHARM
-----------------------------------------------------
Telephone | 407-345-7155
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 26812
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------