=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376825315
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREENS PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 07/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1025 SE PORT ST LUCIE BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-5386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-335-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1025 SE PORT ST LUCIE BLVD
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-5386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-335-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | DR. ULECIA D BOLDIN
-----------------------------------------------------
Credential | PHARM D
-----------------------------------------------------
Telephone | 772-335-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | PS48022
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------