Provider Demographics
NPI:1639113004
Name:KANSAS CVS PHARMACY LLC
Entity Type:Organization
Organization Name:KANSAS CVS PHARMACY LLC
Other - Org Name:CVS PHARMACY #08585
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER PHARMACY 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 1:12691 ANTIOCH RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-1701
Practice Address - Country:US
Practice Address - Phone:913-681-9665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1718874OtherOTHER ID NUMBER-COMMERCIAL NUMBER
9004290Medicare PIN
P00754432Medicare PIN
1718874OtherOTHER ID NUMBER-COMMERCIAL NUMBER