Provider Demographics
NPI:1679804934
Name:OKLAHOMA CVS PHARMACY LLC
Entity Type:Organization
Organization Name:OKLAHOMA CVS PHARMACY LLC
Other - Org Name:CVS PHARMACY #08279
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, MANAGED CARE ADMIN
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: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:401-770-7108
Practice Address - Street 1:2351 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-355-1293
Practice Address - Fax:918-355-1361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200113030KMedicaid
OK200113030JOtherMEDICAID DME
3726051OtherNCPDP
5887790037Medicare NSC
OK200113030KMedicaid
3726051OtherNCPDP