Provider Demographics
NPI:1437253416
Name:HOLIDAY CVS LLC
Entity Type:Organization
Organization Name:HOLIDAY CVS LLC
Other - Org Name:CVS PHARMACY #00368
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PHCY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2937
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 1:3709 N TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-5359
Practice Address - Country:US
Practice Address - Phone:941-355-4155
Practice Address - Fax:941-355-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20466333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1004504OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL105625500Medicaid
FL105625500Medicaid
BC034Medicare PIN
FLP00754232Medicare PIN