Provider Demographics
NPI:1245334184
Name:LOUISIANA CVS PHARMACY, L.L.C.
Entity type:Organization
Organization Name:LOUISIANA CVS PHARMACY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, 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: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 1:3604 PINHOOK RD
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-7129
Practice Address - Country:US
Practice Address - Phone:337-837-2600
Practice Address - Fax:337-837-2617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 332B00000X
LA5843333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1921469OtherOTHER ID NUMBER-COMMERCIAL NUMBER
LA001265225Medicaid
LA001265225Medicaid
5DQ02Medicare PIN
5766170022Medicare NSC