Provider Demographics
NPI:1679677561
Name:HOLIDAY CVS LLC
Entity Type:Organization
Organization Name:HOLIDAY CVS LLC
Other - Org Name:CVS PHARMACY 03130
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHCY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
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: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 1:5 US 27 S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7916
Practice Address - Country:US
Practice Address - Phone:863-465-4810
Practice Address - Fax:239-465-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
FL20550333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105798700Medicaid
1025774OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5140820095Medicare NSC
FLP00949650Medicare PIN
1025774OtherOTHER ID NUMBER-COMMERCIAL NUMBER