Provider Demographics
NPI:1124575865
Name:OHIO CVS STORES LLC
Entity type:Organization
Organization Name:OHIO CVS STORES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DR, PAYER RELATIONS
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: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:401-770-7108
Practice Address - Street 1:210 E EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1336
Practice Address - Country:US
Practice Address - Phone:740-947-2126
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-09
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0191461Medicaid
OH3684582OtherNCPDP
OH3684582OtherNCPDP
OH0191461Medicaid