NPIMap

Organization Active NPI

Walgreen Co

  • Pharmacy
  • Jackson, MS
National Provider Identifier
1104831361
Registry record updated Feb 11, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
0410401WJ Issued in MS
Legal business name
WALGREEN CO
Practice address
3445 Terry Rd
Jackson, MS 39212-4956
Phone
(601) 372-8750
NPI assigned
Jul 29, 2006
Organization subpart
Yes
Parent organization
WALGREENS BOOTS ALLIANCE INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 11, 2019

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

Authorized official

Name
Alyssa Sweeten
Title
Manager
Phone
(217) 709-2386

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X 0410401WJ MS Primary
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

3445 Terry Rd
Jackson, MS 39212-4956

Mailing address

1901 E Voorhees St
M/S 790
Danville, IL 61834-4509
Phone (217) 709-2386

Other identifiers 2

IdentifierTypeStateIssuer
00330387MedicaidMS
2519176OtherOTHER ID NUMBER-COMMERCIAL NUMBER

Other names 1

  • WALGREENS #04191 Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070917000779 TX Part B Supplier - Centralized Flu Biller 0941278253 This NPI is an additional NPI on the enrollment

National Provider Directory

National Provider Directory
Part of
Walgreens Holding Company

Member of 16

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

View all 16

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

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": "1549843200000",
    "number": "1104831361",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1901 E VOORHEES ST",
            "address_2": "M/S 790",
            "city": "DANVILLE",
            "state": "IL",
            "postal_code": "618344509",
            "telephone_number": "217-709-2386",
            "fax_number": "217-709-2344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3445 TERRY RD",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392124956",
            "telephone_number": "601-372-8750"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALGREEN CO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WALGREENS BOOTS ALLIANCE INC.",
        "enumeration_date": "2006-07-29",
        "last_updated": "2019-02-11",
        "status": "A",
        "authorized_official_last_name": "SWEETEN",
        "authorized_official_first_name": "ALYSSA",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "217-709-2386"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "MS",
            "license": "0410401WJ",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00330387",
            "state": "MS"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "2519176",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WALGREENS #04191",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "WALGREENS #04191",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Jackson, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2019; 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.