Basic Information
| Provider Information | |||||||||
| NPI: | 1023188448 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH CAROLINA CVS PHARMACY L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CVS PHARMACY # 01632 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | ONE CVS DRIVE | ||||||||
| Address2: | BOX 1075-PHARMACY ENROLLMENTS | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | 4017707108 | ||||||||
| Practice Location | |||||||||
| Address1: | 9628 REA ROAD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045425072 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 05/17/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAURICIO | ||||||||
| AuthorizedOfficialFirstName: | CRISTIANA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER PHARMACY ENROLLMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4017651500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 09427 | NC | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | P00754581 | 01 | MEDICARE RR | OTHER | 3407271 | 01 | COMMERCIAL NUMBER | OTHER |