1093159774 NPI number — OKLAHOMA CVS PHARMACY LLC

Table of content: (NPI 1093159774)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093159774 NPI number — OKLAHOMA CVS PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA CVS PHARMACY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CVS PHARMACY #10065
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093159774
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CVS DR
Provider Second Line Business Mailing Address:
BOX 1075
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895-6146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-765-1500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 S HWY 97
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAND SPRINGS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74063-6521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-246-9570
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COLBERT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, PAYER RELATIONS
Authorized Official Telephone Number:
401-770-2751

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3727279 . This is a "NCPDP" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100233690G , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100233690U . This is a "DME" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".