Provider Demographics
NPI:1215018601
Name:OHIO CVS STORES LLC
Entity Type:Organization
Organization Name:OHIO CVS STORES LLC
Other - Org Name:CVS PHARMACY # 00396
Other - Org Type:Doing Business As
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:ONE CVS DRIVE
Mailing Address - Street 2:BOX 1075-PHARMACY ENROLLMENTS
Mailing Address - City:WOONSOCKET
Mailing Address - State:ID
Mailing Address - Zip Code:02895
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:401-770-7108
Practice Address - Street 1:200 BROADWAY E
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-1306
Practice Address - Country:US
Practice Address - Phone:740-587-0268
Practice Address - Fax:401-770-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
OH021632650333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3675014OtherNCPDP
FV96411Medicare PIN
OH5660250003Medicare NSC