Provider Demographics
NPI:1710929534
Name:LONGS DRUG STORES CALIFORNIA LLC
Entity Type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA LLC
Other - Org Name:CVS PHARMACY #09832
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:401-770-2381
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2: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:401-770-7108
Practice Address - Street 1:3678 SONOMA BLVD
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2946
Practice Address - Country:US
Practice Address - Phone:707-552-8844
Practice Address - Fax:707-552-8946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
CAPHY494133336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1710929534Medicaid
0564915OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0564915OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA1710929534Medicaid