Provider Demographics
NPI:1891898557
Name:OHIO CVS STORES LLC
Entity Type:Organization
Organization Name:OHIO CVS STORES LLC
Other - Org Name:CVS PHARMACY#04802
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
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:401-765-1500
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 1:600 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9643
Practice Address - Country:US
Practice Address - Phone:330-877-0311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
OH2574700333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3650670OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5660250226Medicare NSC
FV96411Medicare PIN
3650670OtherOTHER ID NUMBER-COMMERCIAL NUMBER