Provider Demographics
NPI:1538463492
Name:WISCONSIN CVS PHARMACY LLC
Entity Type:Organization
Organization Name:WISCONSIN CVS PHARMACY LLC
Other - Org Name:TARGET PHARMACY
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 DR
Mailing Address - Street 2:MAIL CODE 1090
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 1:750 HILLDALE WAY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2644
Practice Address - Country:US
Practice Address - Phone:608-807-3979
Practice Address - Fax:608-807-3989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WI9060-423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1538463492Medicaid
2128274OtherPK
2128274OtherPK