=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477297059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREEN SPECIALTY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2022
-----------------------------------------------------
Last Update Date | 10/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 ENTERPRISE DR
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15275-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-347-3416
-----------------------------------------------------
Fax | 877-231-8302
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 E VOORHEES ST # MS 790
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61834-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-709-2494
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | JENNIFER PONCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-527-2489
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251F00000X
-----------------------------------------------------
Taxonomy Name | Home Infusion Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------