WALGREENS #11113 (WALGREEN CO.) NPI 1003002254
Pharmacy in Gray, TN
About WALGREENS #11113 (WALGREEN CO.)
Walgreens #11113 (walgreen Co.) is a provider established in Gray, Tennessee specializing in pharmacy. The NPI number of Walgreens #11113 (walgreen Co.) is 1003002254 and was assigned on September 2007. The practitioner's primary taxonomy code is 333600000X with license number 4444 (TN). The provider is registered as an organization and their NPI record was last updated 5 years ago. The provider's is doing business as Walgreens #11113. The authorized official of this NPI record is Mr. Alan T Nielsen (Treasurer)
Walgreens #11113 is a medicare supplier with PTAN 0282936022 who does not accept Medicare assignment for all durable medical equipment and supplies. The provider may not accept the Medicare allowable as payment in full and may collect additional payment directly from the patient, and/or charge more than the Medicare allowable.The supplier carries the following product categories: Infusion Drugs or Nebulizer Drugs or Oral Anticancer Drugs or Immunosuppressive Drugs or Blood Glucose Monitors/Supplies (Non-Mail Order) or Epoetin or Oral Antiemetic Drugs.
The CLIA number of Walgreens #11113 is 44D1086038 registered as a "pharmacy" facility with a CLIA Certificate of Waiver. This CLIA certificate is issued to Walgreens #11113 to perform only waived tests. CLIA defines waived tests as simple tests with a low risk for an incorrect result. Waived tests include certain tests listed in CLIA regulations, tests cleared by the FDA for home use and tests approved by the FDA for waived status and that meet CLIA waiver criteria.
| NPI | 1003002254 |
| Provider Name | WALGREENS #11113 (WALGREEN CO.) |
| Provider Location Address | 5104 BOBBY HICKS HWY GRAY, TN 37615 |
| Provider Mailing Address | 1901 E VOORHEES ST MAILSTOP #790 DANVILLE, IL 61834 |
| NPI Entity Type | Organization |
| Is Sole Proprietor? | N/A |
| Is Organization Subpart? | Yes |
| Other Organization Name | WALGREENS #11113 |
| Other Name Type | Doing Business As (3) |
| Enumeration Date | 09-21-2007 |
| Last Update Date | 07-25-2016 |
Primary Taxonomy
| Taxonomy Code | 333600000X |
| Classification | Pharmacy |
| Type | Suppliers |
| License No. | 4444 |
| License State | TN |
| Taxonomy Description | A facility used by pharmacists for the compounding and dispensing of medicinal preparations and other associated professional and administrative services. A pharmacy is a facility whose primary function is to store, prepare and legally dispense prescription drugs under the professional supervision of a licensed pharmacist. It meets any licensing or certification standards set forth by the jurisdiction where it is located. |
Business Address
WALGREENS #11113
5104 BOBBY HICKS HWY
GRAY, TN
ZIP 37615
Phone: (423) 477-3372
Mailing Address
WALGREENS #11113
1901 E VOORHEES ST
MAILSTOP #790
DANVILLE, IL
ZIP 61834
Phone: (217) 709-2386
Fax: (217) 709-2344
Medical Equipment Supplier
The provider carries the following medical supplies product categories:
| PTAN | 0282936022 |
| Accepts Medicare Assignment | NO |
| Specialities List | Pharmacy. |
| Supplies List |
|
| Competitive Bidding | NO |
CLIA Information
The Clinical Laboratory Improvement Amendments (CLIA) of 1988 applies to facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease. The CLIA Program sets standards for clinical laboratory testing and issues certificates. The NPI / CLIA crosswalk information for the NPI number 1003002254 is:
| CLIA Number | 44D1086038 |
| Facility Type | PHARMACY |
| Certificate Type | Certificate of Waiver |
Secondary Taxonomies
The secondary taxonomy codes define the provider type, classification, and specialization. For individual NPIs the license data is associated to each taxonomy code.
| No. | Taxonomy Code | Type | Classification | Specialization | License No. | State | Primary |
|---|---|---|---|---|---|---|---|
| 1 | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | No | |||
Taxonomy Description: a supplier of medical equipment such as respirators, wheelchairs, home dialysis systems, or monitoring systems, that are prescribed by a physician for a patient's use in the home and that are usable for an extended period of time. | |||||||
| 2 | 3336C0003X | Suppliers | Pharmacy | Community/Retail Pharmacy | No | ||
Taxonomy Description: a pharmacy where pharmacists store, prepare, and dispense medicinal preparations and/or prescriptions for a local patient population in accordance with federal and state law; counsel patients and caregivers (sometimes independent of the dispensing process); administer vaccinations; and provide other professional services associated with pharmaceutical care such as health screenings, consultative services with other health care providers, collaborative practice, disease state management, and education classes. | |||||||
Additional Identifiers
Additional identifier(s) currently or formerly used as an identifier for the provider. The codes may include UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers.
| Identifier | Type / Code | Identifier State |
|---|---|---|
| 4440664 | OTHER (01) | |
| P00400633 | MEDICARE PIN (08) | |
| 4440664 | MEDICAID (05) | TN |
| 0282936022 | MEDICARE NSC (07) | |
| PHC049 | MEDICARE PIN (08) |
Other Providers at the same location
The following 5 providers are registered at the same or nearby location.
| NPI | Name / Type | Taxonomy | Address |
|---|---|---|---|
| 1497066609 | MANDY DISHNER PHARM.D. Individual | Pharmacist | 5104 BOBBY HICKS HWY GRAY, TN 37615 (423) 477-3372 |
| 1528379252 | BILLIE REILLY PHARM.D. Individual | Pharmacist | 5104 BOBBY HICKS HWY GRAY, TN 37615 (423) 477-3372 |
| 1770923443 | ABIGAIL BROWN PHARMD Individual | Pharmacist | 5104 BOBBY HICKS HWY GRAY, TN 37615 (423) 477-3372 |
| 1518307917 | ARISSA BROOKE VAUGHN PHARMD Individual | Pharmacist | 5104 BOBBY HICKS HWY GRAY, TN 37615 (423) 477-3372 |
| 1053930420 | DR. MOLLY MARIE KETRON PHARMD Individual | Pharmacist | 5104 BOBBY HICKS HWY JOHNSON CITY, TN 37615 (423) 477-3372 |
NPI Footnotes
What is the National Provider Indentifier (NPI)?
The NPI is 10-position all-numeric identification number assigned by the NPPES to uniquely identify a health care provider.
Provider Location Address
The location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Mailing Address
The mailing address of the provider being identified. This address may contain the same information as the provider location address.
Entity Type Code
The code describing the type of health care provider that is being assigned an NPI.
The entity type codes are:
1 = Person: individual human being who furnishes health care;
2 = Non-person: entity other than an individual human being that furnishes health care (Examples: hospital, SNF, hospital subunit, pharmacy, or HMO)
What is a Subpart?
Subparts are the components and separate physical locations of organization health care providers. Subpart examples include:
Hospital components include outpatient departments, surgical centers, psychiatric units, and laboratories. These components are often separately licensed or certified by States and may exist at physical locations other than that of the hospital of which they are a component.
Provider Other Organization Name
The other organization name is the alternative last name by which the provider is or has been known (if an individual) or other name by which the organization provider is or has been known. The code identifying the type of other name. The provider other organization name codes are:
1 = former name;
2 = professional name;
3 = doing business as (d/b/ a) name;
4 = former legal business name; :
5 = other.
Provider Enumeration Date
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date
The date that a NPI record was last updated or changed.
Primary Taxonomy Code
The primary taxonomy code defines the provider type, classification, and specialization. There could be only one primary taxonomy code per NPI record. For individual NPIs the license data is associated to the taxonomy code.
Authorized Official Name
The name of the person authorized to submit the NPI application or to officially change data for a health care provider.