1730415795 NPI number — MARYLAND CVS PHARMACY, L.L.C.

Table of content: (NPI 1730415795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730415795 NPI number — MARYLAND CVS PHARMACY, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYLAND 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:
1730415795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/31/2018
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:
1008 PULASKI HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAVRE DE GRACE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-939-6427
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2009

Additional Information

Authorized Official

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

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: 029246000 DME , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 029237100 RX , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2134928 . This is a "NCPDP" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 012587300 . 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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