Basic Information
Provider Information | |||||||||
NPI: | 1649216706 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GARFIELD BEACH CVS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CVS PHARMACY #09111 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 CVS DR | ||||||||
Address2: | PO BOX 1075 | ||||||||
City: | WOONSOCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028956146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 16773 BERNARDO CENTER DR | ||||||||
Address2: |   | ||||||||
City: | RANCHO BERNARDO | ||||||||
State: | CA | ||||||||
PostalCode: | 921282509 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8584512630 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2006 | ||||||||
LastUpdateDate: | 08/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COLBERT | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | F | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR, PAYER RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 4017702751 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X |   |   | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 5621114 | 01 |   | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 1649216706 | 05 | CA |   | MEDICAID |