MEDICARE: WISCONSIN CVS PHARMACY, 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	WI
2	3336C0003X	Community/Retail Pharmacy	WI
3	333600000X	Pharmacy	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5134414	OTHER	WI	NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780090415
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN CVS PHARMACY, L.L.C.

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

Provider Business Practice Location Address
First Line	:	433 BROADWAY ST S
Second Line	:
City	:	MENOMONIE
State	:	WI
Zip	:	54751-1822
Country	:	US
Telephone Number	:	715-235-5349
Fax Number	:	715-235-5379

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

Provider Enumeration Date	:	07/02/2014
Last Update Date	:	11/19/2014

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