Provider Demographics
NPI:1558532713
Name:WEST VIRGINIA CVS PHARMACY LLC
Entity Type:Organization
Organization Name:WEST VIRGINIA CVS PHARMACY LLC
Other - Org Name:CVS PHARMACY # 01308
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
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:ONE CVS DRIVE
Mailing Address - Street 2:BOX 1075 - PHARMACY ENROLLMENTS
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:
Practice Address - Street 1:46 MIDDLEWAY PIKE
Practice Address - Street 2:
Practice Address - City:INWOOD
Practice Address - State:WV
Practice Address - Zip Code:25428-3713
Practice Address - Country:US
Practice Address - Phone:304-229-4318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV332B00000X, 333600000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5054717OtherOTHER COMMERCIAL IDENTIFIER - NCPDP NUMBER
WV3810011632Medicaid
6084350001Medicare NSC
WV3810011632Medicaid
P00997963Medicare PIN