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	3336C0003X	Community/Retail Pharmacy
2	291U00000X	Clinical Medical Laboratory
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	333600000X	Pharmacy	13968	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	4582917	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1720093735
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	:	1305 W UNIVERSITY BLVD
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79764-7121
Country	:	US
Telephone Number	:	432-580-0166
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	:	02/09/2026

1365 W UNIVERSITY BLVD
ODESSA, TX
79764-7121

Practice Phone: 432-580-0011
Practice Fax: 432-580-0044