Provider Demographics
NPI:1982983888
Name:HOLIDAY CVS LLC
Entity Type:Organization
Organization Name:HOLIDAY CVS LLC
Other - Org Name:CVS PHARMACY # 07178
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:401-770-2751
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 1:1621 SW 13TH STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1524
Practice Address - Country:US
Practice Address - Phone:352-336-3383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5706986OtherNCPDP
FL004124300Medicaid
FLPH25707OtherPHARMACY STATE LICENSE
FLPH25707OtherPHARMACY STATE LICENSE
FL004124300Medicaid
FLPH25707OtherPHARMACY STATE LICENSE
P00754232Medicare PIN