Provider Demographics
NPI:1538103973
Name:LONGS DRUG STORES CALIFORNIA LLC
Entity Type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA LLC
Other - Org Name:LONGS DRUGS #09620
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:ONE CVS DRIVE
Mailing Address - Street 2:BOX1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:401-770-7108
Practice Address - Street 1:555 KILAUEA AVE
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-3011
Practice Address - Country:US
Practice Address - Phone:808-935-9075
Practice Address - Fax:808-934-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
HIPHY1723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1200106OtherOTHER ID NUMBER-COMMERCIAL NUMBER
HI8268601Medicaid
DL186AMedicare PIN
1200106OtherOTHER ID NUMBER-COMMERCIAL NUMBER