Basic Information
| Provider Information | |||||||||
| NPI: | 1124121801 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOOK SUPERX LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CVS PHARMACY #06666 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DR | ||||||||
| Address2: | PO BOX 1075 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 S LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654823630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2006 | ||||||||
| LastUpdateDate: | 11/12/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | 60004523A | IN | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1503336 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER |