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	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	2017006068	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2640490	OTHER	MO	NCPDP

General Provider Information

NPI Number	:	1407102106
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	:	61834-4509
Country	:	US
Telephone Number	:	217-709-2351
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	6 E SPRINGFIELD RD
Second Line	:
City	:	SULLIVAN
State	:	MO
Zip	:	63080-1310
Country	:	US
Telephone Number	:	573-468-6464
Fax Number	:	573-468-3809

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

Provider Enumeration Date	:	07/31/2012
Last Update Date	:	05/03/2022

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Directions to “WALGREEN CO ” Practice Location

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