Provider Demographics
NPI:1720182520
Name:SOUTH CAROLINA CVS PHARMACY, L.L.C.
Entity Type:Organization
Organization Name:SOUTH CAROLINA CVS PHARMACY, L.L.C.
Other - Org Name:CVS PHARMACY #02191
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PHCY ENROLLMENTS
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 1:4102 OLD BUNCOMBE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29617-3008
Practice Address - Country:US
Practice Address - Phone:864-371-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
SC10820333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4220707OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5765980031Medicare NSC
4220707OtherOTHER ID NUMBER-COMMERCIAL NUMBER
P00986712Medicare PIN