NPIMap

Organization Active NPI

Walgreen Co

Doing business as Walgreens #10591

  • Pharmacy
  • Malone, NY
National Provider Identifier
1063623841
Registry record updated Oct 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
028424 Issued in NY
Legal business name
WALGREEN CO
Doing business as
Walgreens #10591
Practice address
305 W Main St
Malone, NY 12953-1751
Phone
(518) 483-9090
Fax
(518) 483-9096
NPI assigned
May 24, 2007
Last updated
Oct 10, 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 10, 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 028424 NY Primary
Community/Retail Pharmacy 3336C0003X NU

Addresses

Primary practice location

305 W Main St
Malone, NY 12953-1751

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
3354228OtherNCPDP
02892437MedicaidNY

Other names 1

  • WALGREENS #10591 Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX, NY2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070917000779 TX Part B Supplier - Centralized Flu Biller 0941278253 This NPI is an additional NPI on the enrollment
O20221202002040 NY Part B Supplier - Independent Clinical Laboratory 0941278253 9 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Baldwinsville, NY; Rochester, NY; Oceanside, NY; Massena, NY; Henrietta, NY; Geneva, NY; Cicero, NY; Amsterdam, NY…

Other NPIs on the same Medicare enrollment 9

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
33D2219751Walgreens #10591305 W Main St, Malone, NY 12953Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory
Part of
Walgreens Holding Company

Member of 13

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

View all 13

Locations

305 W Main St
Malone, NY 12953
Phone (518) 483-9090

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

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": "1179964800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1728518400000",
    "number": "1063623841",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 E VOORHEES ST",
            "address_2": "MS #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": "305 W MAIN ST",
            "city": "MALONE",
            "state": "NY",
            "postal_code": "129531751",
            "telephone_number": "518-483-9090",
            "fax_number": "518-483-9096"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALGREEN CO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WALGREENS BOOTS ALLIANCE INC",
        "enumeration_date": "2007-05-24",
        "last_updated": "2024-10-10",
        "certification_date": "2024-10-10",
        "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": "NY",
            "license": "028424",
            "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": "NCPDP",
            "identifier": "3354228",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02892437",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WALGREENS #10591",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "WALGREENS #10591",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Malone, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.