MEDICARE: WALGREENS 1261-2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	26812	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26812	OTHER	FL	FL BOARD OF PHARMACY LICENSE

General Provider Information

NPI Number	:	1184100513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREENS 1261-2

Provider Business Mailing Address
First Line	:	8325 SOUTHPARK CIR STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-9075
Country	:	US
Telephone Number	:	407-345-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	8325 SOUTHPARK CIR STE 200
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-9075
Country	:	US
Telephone Number	:	407-345-7155
Fax Number	:

Authorized Official
Title or Position	:	PHARMACIST-IN-CHARGE
Name	:	WANDA ANNETTE DAGHER
Credential	:	BSPHARM
Telephone Number	:	407-345-7155

Provider Enumeration Date	:	07/18/2018
Last Update Date	:	07/18/2018

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