1053601120 NPI number — HOOK-SUPERX 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 1053601120 NPI number — HOOK-SUPERX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOOK-SUPERX 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:
1053601120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2024
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:
6710 HWY 311
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SELLERSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47172-1864
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-246-2241
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2011

Additional Information

Authorized Official

Authorized Official Last Name:
COLBERT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
SR 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 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1563318 . This is a "NCPDP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 201021630A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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