MEDICARE: WALGREENS

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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	15284	NV

General Provider Information

NPI Number	:	1558644914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALGREENS

Provider Business Mailing Address
First Line	:	1025 CORNERSTONE PL
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-1826
Country	:	US
Telephone Number	:	702-580-0123
Fax Number	:

Provider Business Practice Location Address
First Line	:	6101 W LAKE MEAD BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2660
Country	:	US
Telephone Number	:	702-648-2732
Fax Number	:

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	MRS. EMAN GOBRAN
Credential	:	PHD
Telephone Number	:	702-580-0123

Provider Enumeration Date	:	09/22/2011
Last Update Date	:	09/22/2011

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