Provider Demographics
NPI:1609970557
Name:KANSAS CVS PHARMACY, L.L.C.
Entity Type:Organization
Organization Name:KANSAS CVS PHARMACY, L.L.C.
Other - Org Name:CVS PHARMACY # 05272
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MGR PHCY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2937
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:
Mailing Address - Fax:
Practice Address - Street 1:6300 JOHNSON DR
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2611
Practice Address - Country:US
Practice Address - Phone:913-722-3711
Practice Address - Fax:913-677-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
KS2-09940333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710018OtherOTHER ID NUMBER-COMMERCIAL NUMBER
KS200602180EMedicaid
KS200602180EMedicaid
1710018OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5721150028Medicare NSC