Provider Demographics
NPI:1164524443
Name:WOODWARD DETROIT CVS, L.L.C.
Entity Type:Organization
Organization Name:WOODWARD DETROIT CVS, L.L.C.
Other - Org Name:CVS PHARMACY #08170
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
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 1:1 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 1:18640 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1945
Practice Address - Country:US
Practice Address - Phone:586-447-4370
Practice Address - Fax:810-447-4366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
MI5301-006282333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2354506OtherOTHER ID NUMBER-COMMERCIAL NUMBER
MI3161103Medicaid
5603870216Medicare NSC
MI3835Medicare PIN
MI3161103Medicaid