Provider Demographics
NPI:1083087761
Name:CVS
Entity Type:Organization
Organization Name:CVS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:TADAO
Authorized Official - Last Name:TAMURA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:209-712-7055
Mailing Address - Street 1:11181 BOESSOW RD
Mailing Address - Street 2:
Mailing Address - City:GALT
Mailing Address - State:CA
Mailing Address - Zip Code:95632-8321
Mailing Address - Country:US
Mailing Address - Phone:209-369-3648
Mailing Address - Fax:209-369-3104
Practice Address - Street 1:100 W LODI AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3517
Practice Address - Country:US
Practice Address - Phone:209-369-3648
Practice Address - Fax:209-369-3104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty