Provider Demographics
NPI:1093046500
Name:MISSISSIPPI CVS PHARMACY, L.L.C.
Entity Type:Organization
Organization Name:MISSISSIPPI CVS PHARMACY, L.L.C.
Other - Org Name:CVS PHARMACY #05604
Other - Org Type:Doing Business As
Authorized Official - Title/Position: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:401-770-2751
Mailing Address - Street 1:ONE CVS DRIVE
Mailing Address - Street 2:BOX 1075-PHARMACY ENROLLMENTS
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:401-770-7108
Practice Address - Street 1:5025 HIGHWAY 305 N
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3602
Practice Address - Country:US
Practice Address - Phone:662-890-3548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2587915OtherNCPDP
MS03337761Medicaid
MS07158876OtherMEDICAID DME
5983700041Medicare NSC
302G735488Medicare PIN
P00962172Medicare PIN