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	3336C0002X	Clinic Pharmacy
3	333600000X	Pharmacy	07969/01.2	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	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	2587559	OTHER	MS	NCPDP

General Provider Information

NPI Number	:	1417192766
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	:	847-527-2489
Fax Number	:	217-709-2344

Provider Business Practice Location Address
First Line	:	4910 POPLAR SPRINGS DR
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39305-1685
Country	:	US
Telephone Number	:	601-483-3997
Fax Number	:	601-483-9872

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

Provider Enumeration Date	:	12/15/2008
Last Update Date	:	06/03/2026

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Directions to “WALGREEN CO ” Practice Location

Language	Start Address	Practice Location

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