Provider Demographics
NPI:1083023378
Name:CVS/PHARMACY
Entity Type:Organization
Organization Name:CVS/PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:ROTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:910-256-3761
Mailing Address - Street 1:124 MENDENHALL DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9108
Mailing Address - Country:US
Mailing Address - Phone:704-219-5135
Mailing Address - Fax:
Practice Address - Street 1:1712 EASTWOOD RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3641
Practice Address - Country:US
Practice Address - Phone:910-256-3761
Practice Address - Fax:910-256-9345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC234323336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy