=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912278367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREENS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2012
-----------------------------------------------------
Last Update Date | 01/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6105 NE 114TH AVE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98662-6335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-254-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3508 NE 109TH AVE APT T3
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682-7210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-254-3848
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHARMACIST
-----------------------------------------------------
Name | BETHLEHEM SHAWLE
-----------------------------------------------------
Credential | DOCTOR OF PHARMACIST
-----------------------------------------------------
Telephone | 360-254-3848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | PH00070793
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------