Provider Demographics
NPI:1063456317
Name:ARIZONA CVS STORES LLC
Entity Type:Organization
Organization Name:ARIZONA CVS STORES LLC
Other - Org Name:CVS PHARMACY 08828
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHARMACY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
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 1:2090 E FRY BLVD
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2707
Practice Address - Country:US
Practice Address - Phone:520-458-1254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0353627OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5722810028Medicare NSC
0353627OtherOTHER ID NUMBER-COMMERCIAL NUMBER