Provider Demographics
NPI:1598824641
Name:LOUISIANA CVS PHARMACY, L.L.C.
Entity Type:Organization
Organization Name:LOUISIANA CVS PHARMACY, L.L.C.
Other - Org Name:CVS PHARMACY 05617
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:401-770-1624
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:PO 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:
Practice Address - Street 1:29881 WALKER SOUTH RD
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:LA
Practice Address - Zip Code:70785
Practice Address - Country:US
Practice Address - Phone:225-665-4580
Practice Address - Fax:225-665-4560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
LA5440333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1927904OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA001266108Medicaid
LA001266108Medicaid
5DQ02Medicare PIN