1316121262 NPI number — SOUTH CAROLINA CVS PHARMACY, L.L.C.

Table of content: (NPI 1316121262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316121262 NPI number — SOUTH CAROLINA CVS PHARMACY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CAROLINA CVS PHARMACY, L.L.C.
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:
Provider Other Organization Name Type Code:
6
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:
1316121262
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2010
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-PHARMACY ENROLLMENTS
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:
401-770-7108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9625 HIGHWAY 78
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADSON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29456-3913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-818-1190
Provider Business Practice Location Address Fax Number:
401-770-7108
Provider Enumeration Date:
12/27/2007

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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 10743 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 798079 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4227523 . This is a "NCPDP #" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DE3132 . This is a "SC DME" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 012037400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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