Provider Demographics
NPI:1720014079
Name:HIGHLAND PARK CVS, L.L.C.
Entity Type:Organization
Organization Name:HIGHLAND PARK CVS, L.L.C.
Other - Org Name:CVS PHARMACY #18066
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. 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:401-770-2751
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:
Practice Address - Street 1:2712 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-3311
Practice Address - Country:US
Practice Address - Phone:618-466-0825
Practice Address - Fax:618-467-0544
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCHNUCK MARKETS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X, 3336C0003X
IL05412051332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1465853OtherOTHER ID NUMBER-COMMERCIAL NUMBER
IL430726776269Medicaid
IL=========269Medicaid