Provider Demographics
NPI:1922397439
Name:MARYLAND CVS PHARMACY, LLC
Entity Type:Organization
Organization Name:MARYLAND CVS PHARMACY, LLC
Other - Org Name:CVS PHARMACY # 02956
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:F
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2151
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:401-770-7108
Practice Address - Street 1:5414 ROTARY AVE
Practice Address - Street 2:
Practice Address - City:NEW MARKET
Practice Address - State:MD
Practice Address - Zip Code:21774-6117
Practice Address - Country:US
Practice Address - Phone:301-865-0019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2135716OtherNCPDP
MD043101000 DMEMedicaid
MD043100100 RXMedicaid
MD043101000 DMEMedicaid
MD5911980161Medicare NSC