NPIMap

Organization Active NPI

Walgreen Eastern Co Inc

Doing business as Walgreens #04115

  • Pharmacy
  • Philadelphia, PA
National Provider Identifier
1033124029
Registry record updated Oct 8, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
PP415296L Issued in PA
Legal business name
WALGREEN EASTERN CO INC
Doing business as
Walgreens #04115
Practice address
4201 N Broad St
Philadelphia, PA 19140-3019
Phone
(215) 457-3877
Fax
(215) 457-3363
NPI assigned
Jul 29, 2006
Last updated
Oct 8, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
WALGREENS BOOTS ALLIANCE INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 8, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jennifer Ponce
Title
Manager
Phone
(847) 527-2489

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X PP415296L PA Primary
Community/Retail Pharmacy 3336C0003X NU

Addresses

Primary practice location

4201 N Broad St
Philadelphia, PA 19140-3019

Mailing address

1901 E Voorhees St
Mailstop #790
Danville, IL 61834-4509
Phone (847) 527-2489

Other identifiers 2

IdentifierTypeStateIssuer
3973054OtherOTHER ID NUMBER-COMMERCIAL NUMBER
07669700066MedicaidPA

Other names 1

  • WALGREENS #04115 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, PA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20071211000174 TX Part B Supplier - Centralized Flu Biller 7618929993 This NPI is an additional NPI on the enrollment
O20100930051889 PA DME Supplier - Pharmacy 7618929993 Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory
Tax ID family
Walgreens Pharmacy 2267338 organizations share this tax ID, including this one
Part of
Walgreens Holding Company

Organizations with this tax ID in the same state 3

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

Member of 3

Organizations this organization is a member of, according to the National Provider Directory.

Locations

4201 N Broad St
Philadelphia, PA 19140
Phone (215) 457-3877

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154131200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728345600000",
    "number": "1033124029",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 E VOORHEES ST",
            "address_2": "MAILSTOP #790",
            "city": "DANVILLE",
            "state": "IL",
            "postal_code": "618344509",
            "telephone_number": "847-527-2489",
            "fax_number": "217-709-2344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4201 N BROAD ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191403019",
            "telephone_number": "215-457-3877",
            "fax_number": "215-457-3363"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALGREEN EASTERN CO INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WALGREENS BOOTS ALLIANCE INC",
        "enumeration_date": "2006-07-29",
        "last_updated": "2024-10-08",
        "certification_date": "2024-10-08",
        "status": "A",
        "authorized_official_last_name": "PONCE",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "847-527-2489"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "PA",
            "license": "PP415296L",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "3973054",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "07669700066",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WALGREENS #04115",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALGREENS #04115",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 8, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.