Basic Information
| Provider Information | |||||||||
| NPI: | 1316989148 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONGS DRUG STORES CALIFORNIA, L.L.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONGS DRUGS #09671 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DR # 1075 | ||||||||
| Address2: | |||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 46 047 KAMEHAMEHA HWY | ||||||||
| Address2: | |||||||||
| City: | KANEOHE | ||||||||
| State: | HI | ||||||||
| PostalCode: | 96744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8082354551 | ||||||||
| FaxNumber: | 8082364626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2006 | ||||||||
| LastUpdateDate: | 03/02/2011 | ||||||||
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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 | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | PHY196 | HI | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1201057 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 08274101 | 05 | HI | MEDICAID |