Basic Information
| Provider Information | |||||||||
| NPI: | 1609819911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LONGS DRUG STORES CALIFORNIA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LONGS DRUGS #09303 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DR | ||||||||
| Address2: | P.O. BOX 1075 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | 4017707108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 S KIHEI RD | ||||||||
| Address2: | STE B | ||||||||
| City: | KIHEI | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967535220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8088792033 | ||||||||
| FaxNumber: | 8088747633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | PHY473 | HI | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1202679 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 08259801 | 05 | HI | MEDICAID |