Provider Demographics
NPI:1710080551
Name:GEORGIA CVS PHARMACY LLC
Entity Type:Organization
Organization Name:GEORGIA CVS PHARMACY LLC
Other - Org Name:CVS PHARMACY # 05618
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:401-770-2751
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 1:11685 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-2573
Practice Address - Country:US
Practice Address - Phone:912-723-4271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA332B00000X
GA005504333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000186711AMedicaid
1124623OtherOTHER ID NUMBER-COMMERCIAL NUMBER
AL1710080551Medicaid
AL1710080551Medicaid
GA5754010234Medicare NSC
1124623OtherOTHER ID NUMBER-COMMERCIAL NUMBER