1255434080 NPI number — GEORGIA CVS PHARMACY, L.L.C.

Table of content: (NPI 1255434080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255434080 NPI number — GEORGIA CVS PHARMACY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA 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:
1255434080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2012
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:
PO 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:
30 ORVIN LANCE CONNECTOR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE RIDGE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30513-4238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-632-8097
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COLBERT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR, 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 , with the licence number: 006746 , registered in the state of GA ; 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: 1130967 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000341525A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007619500 . 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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