1174638290 NPI number — HOLIDAY CVS LLC

Table of content: (NPI 1174638290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174638290 NPI number — HOLIDAY CVS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLIDAY CVS 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:
NAVARRO DISCOUNT PHARMACY #10703
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:
1174638290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2023
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:
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:
3141 W 76TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33018-3885
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-636-7779
Provider Business Practice Location Address Fax Number:
305-557-4707
Provider Enumeration Date:
08/20/2006

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: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 012817000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012817001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1080655 . This is a "NCPDP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com