Active NPI
Walgreen Co
- Pharmacy
- Lake Wales, FL
National Provider Identifier
1164437273
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacy
- License
- PH0008734
- Legal business name
- WALGREEN CO
- Practice address
- 1903 State Road 60 E
Lake Wales, FL 33853-4329 - Phone
- (863) 676-9496
- NPI assigned
- Jul 29, 2006
- Organization subpart
- Yes
- Parent organization
- WALGREENS BOOTS ALLIANCE INC
NPPES NPI Registry
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) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | PH0008734 | FL | Primary |
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
1903 State Road 60 E
Lake Wales, FL 33853-4329
Mailing address
1901 E Voorhees St
Ms 790
Danville, IL 61834-4515
Phone (847) 527-2489
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 101457900 | Medicaid | FL | |
| 101457901 DME | Medicaid | FL | |
| 1050878 | Other | OTHER ID NUMBER-COMMERCIAL NUMBER |
Other names 1
- WALGREENS #04380
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in TX, FL
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070917000779 | TX | Part B Supplier - Centralized Flu Biller | 0941278253 | This NPI is an additional NPI on the enrollment |
| O20201209002916 | FL | Part B Supplier - Independent Clinical Laboratory | 0941278253 | This NPI is an additional NPI on the enrollment |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2013110 | Walgreen Co | Certificate of waiver | Nov 29, 2027 |
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.
-
- Home Infusion Therapy Pharmacy
- Sauk Rapids, MN
- NPI 1891746111
Member Of
-
- Home Infusion Therapy Pharmacy
- Nashville, TN
- NPI 1326279746
Member Of
Networks
- Optimum HealthCare HMO Network
- Freedom Health HMO Network
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.
-
- Health Service Clinic/Center
- Ocala, FL
- NPI 1336686989
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": "1761091200000",
"number": "1164437273",
"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": "618344515",
"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": "1903 STATE ROAD 60 E",
"city": "LAKE WALES",
"state": "FL",
"postal_code": "338534329",
"telephone_number": "863-676-9496"
}
],
"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": "2025-10-22",
"certification_date": "2025-10-22",
"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": null,
"license": null,
"primary": false
},
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": "FL",
"license": "PH0008734",
"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": "101457900",
"state": "FL"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "101457901 DME",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
"identifier": "1050878",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "WALGREENS #04380",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "WALGREENS #04380",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Lake Wales, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 22, 2025; 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.