Provider Demographics
NPI:1487043527
Name:MISSISSIPPI CVS PHARMACY, LLC
Entity Type:Organization
Organization Name:MISSISSIPPI CVS PHARMACY, LLC
Other - Org Name:CVS PHARMACY # 10755
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:BOX 1075
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 1:4422 KALANI DR
Practice Address - Street 2:
Practice Address - City:DIAMONDHEAD
Practice Address - State:MS
Practice Address - Zip Code:39525-3321
Practice Address - Country:US
Practice Address - Phone:228-255-7343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-13
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030634Medicaid
MS2590051OtherNCPDP
MS00023721 DMEMedicaid
MS00030634Medicaid
MS302G735488Medicare PIN