Provider Demographics
NPI:1174538490
Name:WALGREEN CO
Entity type:Organization
Organization Name:WALGREEN CO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR CORPORATE VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KERMIT
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-914-3154
Mailing Address - Street 1:1901 E VOORHEES ST
Mailing Address - Street 2:MS 720
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61834-4509
Mailing Address - Country:US
Mailing Address - Phone:217-554-8964
Mailing Address - Fax:217-554-8546
Practice Address - Street 1:5627 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4921
Practice Address - Country:US
Practice Address - Phone:773-728-7916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WALGREEN CO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-29
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
IL54008022333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL362127039884Medicaid
1446889OtherOTHER ID NUMBER-COMMERCIAL NUMBER
P00720805Medicare PIN
0329920035Medicare NSC
PHC049Medicare PIN