MEDICARE: HIGHLAND PARK CVS, L.L.C

Medicare Provider Information

Scope of Practice

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

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1492494	OTHER	IL	NCPDP

General Provider Information

NPI Number	:	1134578354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLAND PARK CVS, L.L.C

Provider Business Mailing Address
First Line	:	ONE CVS DRIVE
Second Line	:
City	:	WOONSOCKET
State	:	RI
Zip	:	02895
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2650 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-1523
Country	:	US
Telephone Number	:	773-525-0179
Fax Number	:

Authorized Official
Title or Position	:	SR DIRECTOR PAYER RELATIONS
Name	:	SUSAN COLBERT
Credential	:
Telephone Number	:	401-765-1500

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	10/26/2016

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