=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790055945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREENS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2012
-----------------------------------------------------
Last Update Date | 01/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 FREDERICK BLVD
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-3314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-391-9123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1144 KINGSBURY DR
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23322-4264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-472-8580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | JEFF VANSCHAACK
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 757-472-8580
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 14803
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 0202204450
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------