1558303362 NPI number — LONGS DRUG STORES CALIFORNIA LLC

Table of content: (NPI 1558303362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558303362 NPI number — LONGS DRUG STORES CALIFORNIA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGS DRUG STORES CALIFORNIA 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:
1558303362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/23/2011
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:
P.O. 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:
401-770-7108

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 DE ANZA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN MATEO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94402-3987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-572-2514
Provider Business Practice Location Address Fax Number:
650-572-2790
Provider Enumeration Date:
06/13/2006

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 RELATIIONS
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: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY49461 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1558303362 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0578089 . This is a "OTHER ID NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0578089 . This is a "OTHER ID NUMBER-COMMERCIAL NUMBER" identifier . This identifiers is of the category "OTHER".




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