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General NPI Number Information
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NPI Number | 1558611897
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Entity Type | Organization
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Legal Business Name | WALGREENS
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Dates
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Enumeration Date | 09/13/2012
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Last Update Date | 09/13/2012
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Provider Practice Location Address
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Address Line | 5716 ATON AVE
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City | WESTWORTH VILLAGE
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State | TX
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Zip | 76114
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Country | US
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Telephone | 614-584-6965
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Fax |
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Provider Business Mailing Address
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Address Line | 3809 E BELKNAP
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City | FORT WORTH
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State | TX
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Zip | 76111
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Country | US
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Telephone | 817-834-7283
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Fax |
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Authorized Official
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Title or Position | STAFF PHARMACIST
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Name | ADA VANDYKE
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Credential | PHARMD
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Telephone | 614-584-6965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 52182
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License Number State | TX
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