Provider Demographics
NPI:1518042688
Name:HIGHLAND PARK CVS, L.L.C.
Entity Type:Organization
Organization Name:HIGHLAND PARK CVS, L.L.C.
Other - Org Name:CVS PHARMACY #10599
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. 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 DRIVE
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:815-458-6158
Practice Address - Street 1:245 S BROADWAY STREET
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416
Practice Address - Country:US
Practice Address - Phone:815-634-0455
Practice Address - Fax:815-634-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000679332B00000X
IL054-0083923336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL054-008392OtherPHARMACY LIC
IL363484164014Medicaid
IL0194080007Medicare NSC