Provider Demographics
NPI:1770526949
Name:LONGS DRUG STORES CALIFORNIA LLC
Entity type:Organization
Organization Name:LONGS DRUG STORES CALIFORNIA LLC
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:P.O. 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 1:1201 W MAIN ST STE 14
Practice Address - Street 2:
Practice Address - City:RIPON
Practice Address - State:CA
Practice Address - Zip Code:95366-3027
Practice Address - Country:US
Practice Address - Phone:209-599-4686
Practice Address - Fax:209-599-2308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 332B00000X
CAPHY494473336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1770526949Medicaid
0599033OtherOTHER ID NUMBER-COMMERCIAL NUMBER
0599033OtherOTHER ID NUMBER-COMMERCIAL NUMBER
CA1770526949Medicaid