Basic Information
| Provider Information | |||||||||
| NPI: | 1699004747 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OHIO CVS STORES, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CVS PHARMACY #11228 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DRIVE | ||||||||
| Address2: | BOX 1075 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | 4194747137 | ||||||||
| Practice Location | |||||||||
| Address1: | 3316 NAVARRE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | OREGON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436163314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196985408 | ||||||||
| FaxNumber: | 4196987686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2009 | ||||||||
| LastUpdateDate: | 11/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR, PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | OH | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 3059129 | 05 | OH | MEDICAID |