Provider Demographics
NPI:1205931045
Name:HOLIDAY CVS LLC
Entity type:Organization
Organization Name:HOLIDAY CVS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, PHCY ENROLLMENTS
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:401-770-2751
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 1:238 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:EAST PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32131-6059
Practice Address - Country:US
Practice Address - Phone:386-328-6713
Practice Address - Fax:904-329-5254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
FL20632333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105636100Medicaid
1041920OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL105636100Medicaid
FLBC034CMedicare PIN
1041920OtherOTHER ID NUMBER-COMMERCIAL NUMBER