Provider Demographics
NPI:1881848703
Name:LONGS DRUG STORES CALIFORNIA L.L.C.
Entity Type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA L.L.C.
Other - Org Name:LONGS DRUGS #06889
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, PHARMACY 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:401-765-2751
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 1:1481 S KING ST
Practice Address - Street 2:SUITE 111
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2697
Practice Address - Country:US
Practice Address - Phone:808-945-7875
Practice Address - Fax:808-951-8507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
HIPHY758333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI628505Medicaid
1240249OtherNCPDP
HI628505Medicaid
DL186AMedicare PIN