MEDICARE: LONGS DRUG STORES CALIFORNIA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	PHY49516	CA
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0512447	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134162498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUG STORES CALIFORNIA LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	P.O. BOX 1075
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:	401-770-7108

Provider Business Practice Location Address
First Line	:	150 S MAIN ST
Second Line	:
City	:	FORT BRAGG
State	:	CA
Zip	:	95437-4205
Country	:	US
Telephone Number	:	707-961-0464
Fax Number	:	707-961-0460

Authorized Official
Title or Position	:	DIRECTOR, PAYER RELATIONS
Name	:	SUSAN COLBERT
Credential	:
Telephone Number	:	401-770-2751

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	03/02/2012

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