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	291U00000X	Clinical Medical Laboratory
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	3336C0003X	Community/Retail Pharmacy
4	333600000X	Pharmacy	16464	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	4594049	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1942217955
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	:	1105 GOLIAD RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-1838
Country	:	US
Telephone Number	:	210-533-7602
Fax Number	:	210-533-3916

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	06/16/2025

211 CALLE MORSE
ARROYO, PR
00714-2350

Practice Phone: 787-839-3980
Practice Fax: 787-271-2515