Provider Demographics
NPI:1043666407
Name:CVS PHARMACY, INC.
Entity Type:Organization
Organization Name:CVS PHARMACY, INC.
Other - Org Name:CVS PHARMACY # 10665
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. 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 1:1555 EAST RENNER RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3074
Mailing Address - Country:US
Mailing Address - Phone:972-238-1395
Mailing Address - Fax:
Practice Address - Street 1:1555 EAST RENNER RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-3074
Practice Address - Country:US
Practice Address - Phone:972-238-1395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470903Medicaid
TX5918947OtherNCPDP
TX1284731059Medicare NSC
TXPH0708Medicare PIN