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	1482974	OTHER	IL	NCPDP

General Provider Information

NPI Number	:	1306086624
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	:	BOX 1075 - PHARMACY ENROLLMENTS
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	:	3615 N. CENTRAL AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Authorized Official
Title or Position	:	MGR PHCY ENROLLMENTS
Name	:	CRISTIANA MAURICIO
Credential	:
Telephone Number	:	401-765-1500

Provider Enumeration Date	:	02/26/2009
Last Update Date	:	10/14/2014

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