Provider Demographics
NPI:1427393115
Name:HIGHLAND PARK CVS LLC
Entity Type:Organization
Organization Name:HIGHLAND PARK CVS LLC
Other - Org Name:CVS PHARMACY #05887
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 1:1 CVS DR
Mailing Address - Street 2:
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 1:1111 N DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:SAVOY
Practice Address - State:IL
Practice Address - Zip Code:61874-9604
Practice Address - Country:US
Practice Address - Phone:217-351-2123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1487568OtherNCPDP
IL1487568OtherNCPDP
IL1487568OtherNCPDP
IL=========064Medicaid