Provider Demographics
NPI:1437405297
Name:MISSOURI CVS PHARMACY LLC
Entity Type:Organization
Organization Name:MISSOURI CVS PHARMACY LLC
Other - Org Name:CVS PHARMACY #10053
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 1:1 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:
Mailing Address - Fax:
Practice Address - Street 1:400 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1577
Practice Address - Country:US
Practice Address - Phone:636-279-1516
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-31
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1437405297Medicaid
2640387OtherNCPDP
5724300058Medicare NSC
MO1437405297Medicaid