Provider Demographics
NPI:1033218342
Name:MISSOURI CVS PHARMACY, L.L.C.
Entity Type:Organization
Organization Name:MISSOURI CVS PHARMACY, L.L.C.
Other - Org Name:CVS PHARMACY #05661
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PHCY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2937
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:PO BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 E NORTH AVE
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:MO
Practice Address - Zip Code:64012-2016
Practice Address - Country:US
Practice Address - Phone:816-331-9716
Practice Address - Fax:816-331-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MO2004023160333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600198857Medicaid
2618417OtherOTHER ID NUMBER-COMMERCIAL NUMBER
2618417OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5724300047Medicare NSC
9004340Medicare PIN