MEDICARE: WALGREEN CO.

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1265170088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREEN CO.

Provider Business Mailing Address
First Line	:	1901 E VOORHEES ST # MS 790
Second Line	:
City	:	DANVILLE
State	:	IL
Zip	:	61834-4509
Country	:	US
Telephone Number	:	217-709-2351
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	11053 SOUTHWEST HWY
Second Line	:
City	:	PALOS HILLS
State	:	IL
Zip	:	60465-2321
Country	:	US
Telephone Number	:	708-974-0532
Fax Number	:	708-974-0641

Authorized Official
Title or Position	:	MANAGER
Name	:	KIRA L TAYLOR
Credential	:
Telephone Number	:	217-709-2351

Provider Enumeration Date	:	05/23/2022
Last Update Date	:	05/23/2022

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