Provider Demographics
NPI:1710325055
Name:PENNSYLVANIA CVS PHARMACY, LLC
Entity Type:Organization
Organization Name:PENNSYLVANIA CVS PHARMACY, LLC
Other - Org Name:CVS PHARMACY # 05241
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:F
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-765-1500
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075 PHARMACY ENROLLMENTS
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 1:3265 COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:CHALFONT
Practice Address - State:PA
Practice Address - Zip Code:18914
Practice Address - Country:US
Practice Address - Phone:401-765-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015538870419Medicaid
PA1710325055OtherPACE
PA3999325OtherNCPDP
PA5619370401Medicare NSC
PA168230Medicare PIN