Basic Information
| Provider Information | |||||||||
| NPI: | 1932203882 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOLIDAY CVS LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CVS PHARMACY 03930 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DR | ||||||||
| Address2: | PO BOX 1075 | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 S HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132599911 | ||||||||
| FaxNumber: | 8132580306 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PHCY ENROLLMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | 20387 | FL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1063267 | 01 | OTHER ID NUMBER-COMMERCIAL NUMBER | OTHER | 105684100 | 05 | FL | MEDICAID |