MEDICARE: WALGREEN CO

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	5301005766	MI

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2350065	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1265447379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREEN CO

Provider Business Mailing Address
First Line	:	1901 E VOORHEES ST
Second Line	:	MS 790
City	:	DANVILLE
State	:	IL
Zip	:	61834-4515
Country	:	US
Telephone Number	:	847-527-2489
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	800 LEONARD ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-4148
Country	:	US
Telephone Number	:	616-458-8300
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JENNIFER PONCE
Credential	:
Telephone Number	:	847-527-2489

Provider Enumeration Date	:	07/29/2006
Last Update Date	:	06/03/2026

800 LEONARD ST NW
GRAND RAPIDS, MI
49504-4148

Practice Phone: 616-458-8300
Practice Fax: 616-458-3691

800 LEONARD ST NW APT 115
GRAND RAPIDS, MI
49504-4148