NPIMap

Organization Active NPI

Walgreen Co

Doing business as Walgreens Specialty Pharmacy #21162

  • Pharmacy
  • Jacksonville, FL
National Provider Identifier
1730673385
Registry record updated Nov 11, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
Legal business name
WALGREEN CO
Doing business as
Walgreens Specialty Pharmacy #21162
Practice address
1301 Palm Ave Ste 210
Jacksonville, FL 32207-8432
Phone
(904) 559-3504
NPI assigned
Jun 18, 2018
Last updated
Nov 11, 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 Nov 11, 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 4

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X Primary
Pharmacy 333600000X PH31617 FL
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

1301 Palm Ave Ste 210
Jacksonville, FL 32207-8432

Mailing address

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

Other identifiers 4

IdentifierTypeStateIssuer
000774800MedicaidFL
100964900MedicaidFL
000774801MedicaidFL
5738159OtherFLNCPDP

Other names 1

  • Walgreens Specialty Pharmacy #21162 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

Locations

1301 W Palm Ave
Ste 210
Jacksonville, FL 32254

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.

NPI Registry JSON

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

{
    "created_epoch": "1529280000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1731283200000",
    "number": "1730673385",
    "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": "1301 PALM AVE STE 210",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322078432",
            "telephone_number": "904-559-3504"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WALGREEN CO",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "WALGREENS BOOTS ALLIANCE INC",
        "enumeration_date": "2018-06-18",
        "last_updated": "2024-11-11",
        "certification_date": "2024-11-11",
        "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": null,
            "license": null,
            "primary": true
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "FL",
            "license": "PH31617",
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000774800",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100964900",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000774801",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP",
            "identifier": "5738159",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Walgreens Specialty Pharmacy #21162",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jacksonville, FL

Sources for this page

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