Provider Demographics
NPI:1194028761
Name:HIGHLAND PARK CVS LLC
Entity Type:Organization
Organization Name:HIGHLAND PARK CVS LLC
Other - Org Name:CVS PHARMACY #07788
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: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:BOX 1075 - PHARMACY ENROLLMENTS
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:2075 S LAKE ST
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-4232
Practice Address - Country:US
Practice Address - Phone:847-566-6347
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1485285OtherNCPDP
IL=========051Medicaid
IL4723660260Medicare NSC
ILP00959569Medicare PIN
IL1485285OtherNCPDP