NPIMap

Organization Active NPI

Walgreen Co

Doing business as Walgreens #12639

  • Pharmacy
  • Salt Lake City, UT
National Provider Identifier
1275705493
Registry record updated Apr 28, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
6971842-1703 Issued in UT
Legal business name
WALGREEN CO
Doing business as
Walgreens #12639
Practice address
4690 S Holladay Blvd
Salt Lake City, UT 84117-5243
Phone
(509) 943-9121
NPI assigned
Mar 27, 2008
Last updated
Apr 28, 2016By the provider in NPPES
Organization subpart
Yes
Parent organization
WALGREENS BOOTS ALLIANCE INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 28, 2016

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

Authorized official

Name
Mr. Alan T Nielsen
Title
Treasurer
Phone
(847) 315-3523

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X NU
Pharmacy 333600000X 6971842-1703 UT Primary
Community/Retail Pharmacy 3336C0003X NU

Addresses

Primary practice location

4690 S Holladay Blvd
Salt Lake City, UT 84117-5243

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
4611023OtherNCPDP
1275705493MedicaidUT

Other names 1

  • WALGREENS #12639 Doing business as

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 13

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

View all 13

NPI Registry JSON

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

{
    "created_epoch": "1206576000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1461801600000",
    "number": "1275705493",
    "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": "217-709-2386",
            "fax_number": "217-709-2344"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4690 S HOLLADAY BLVD",
            "city": "SALT LAKE CITY",
            "state": "UT",
            "postal_code": "841175243",
            "telephone_number": "509-943-9121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALGREEN CO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WALGREENS BOOTS ALLIANCE INC",
        "enumeration_date": "2008-03-27",
        "last_updated": "2016-04-28",
        "status": "A",
        "authorized_official_last_name": "NIELSEN",
        "authorized_official_first_name": "ALAN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "TREASURER",
        "authorized_official_telephone_number": "847-315-3523",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "UT",
            "license": "6971842-1703",
            "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": "4611023",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1275705493",
            "state": "UT"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "WALGREENS #12639",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Salt Lake City, UT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 28, 2016; 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.