Provider Demographics
NPI:1558303370
Name:LONGS DRUG STORES CALIFORNIA LLC
Entity Type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA LLC
Other - Org Name:CVS PHARMACY #09901
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 1:1 CVS DR
Mailing Address - Street 2:P.O. 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:401-771-7108
Practice Address - Street 1:1125 BRANHAM LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3702
Practice Address - Country:US
Practice Address - Phone:408-267-0911
Practice Address - Fax:408-267-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY496693336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0591962OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA1558303370Medicaid
CA1558303370Medicaid
DL721FMedicare PIN