=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982835617
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WALGREEN CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2009
-----------------------------------------------------
Last Update Date | 04/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 W FINNIE FLAT RD
-----------------------------------------------------
City | CAMP VERDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86322-7398
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-239-3187
-----------------------------------------------------
Fax | 928-567-3935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 E VOORHEES ST MS #790
-----------------------------------------------------
City | DANVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61834-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-709-2351
-----------------------------------------------------
Fax | 217-709-2344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | KIRA TAYLOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-709-2351
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | Y005173
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------