Basic Information
Provider Information | |||||||||
NPI: | 1700176591 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RHODE ISLAND CVS PHARMACY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CVS PHARMACY # 05107 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 CVS DR | ||||||||
Address2: | BOX 1075 - PHARMACY ENROLLMENTS | ||||||||
City: | WOONSOCKET | ||||||||
State: | RI | ||||||||
PostalCode: | 028956146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4017651500 | ||||||||
FaxNumber: | 4017707108 | ||||||||
Practice Location | |||||||||
Address1: | 1285 S COUNTY TRL | ||||||||
Address2: |   | ||||||||
City: | EAST GREENWICH | ||||||||
State: | RI | ||||||||
PostalCode: | 028181620 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4018860902 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/13/2011 | ||||||||
LastUpdateDate: | 11/17/2011 | ||||||||
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 | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 3336C0003X |   |   | N |   | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X |   |   | Y |   | Suppliers | Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | RI85276 | 05 | RI |   | MEDICAID | 3910057 - DME | 05 | RI |   | MEDICAID | 4107430 | 01 | RI | NCPDP | OTHER |