1710081500 NPI number — PENNSYLVANIA CVS PHARMACY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710081500 NPI number — PENNSYLVANIA CVS PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNSYLVANIA 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:
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:
1710081500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 1075
Provider Second Line Business Mailing Address:
ONE CVS DRIVE
Provider Business Mailing Address City Name:
WOONSOCKET
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02895
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:
290 POTTSTOWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENNSBURG
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18073-1807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-541-2300
Provider Business Practice Location Address Fax Number:
401-770-7108
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COLBERT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR MANAGED CARE ADMINISTRATIO
Authorized Official Telephone Number:
401-765-1500

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  PP481533 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PP481533 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: PP481533 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1015538870005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3985516 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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