Provider Demographics
NPI:1003118696
Name:GRAND ST. PAUL CVS, L.L.C.
Entity Type:Organization
Organization Name:GRAND ST. PAUL CVS, L.L.C.
Other - Org Name:CVS PHARMACY # 05920
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-765-1500
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:401-770-7108
Practice Address - Street 1:600 CENTRAL AVE. E
Practice Address - Street 2:
Practice Address - City:ST. MICHAEL
Practice Address - State:MN
Practice Address - Zip Code:55376-4584
Practice Address - Country:US
Practice Address - Phone:763-497-6632
Practice Address - Fax:401-770-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1003118696Medicaid
MN2430469OtherNCPDP
MN5603920048Medicare NSC
MN1003118696Medicaid