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	5874	MO

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2630209	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1821003070
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	:	2640 E SUNSHINE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2045
Country	:	US
Telephone Number	:	417-885-1274
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	:	02/06/2026

2101 E JEFFERSON ST , KAISER PERMANENTE SPRINGFIELD MEDICARE ENROLLMENT
ROCKVILLE, MD
20852-4908

Practice Phone: 701-922-1000
Practice Fax: 703-922-1039