Healthcare Provider Details

I. General information

NPI: 1962511436
Provider Name (Legal Business Name): PROCARE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 01/31/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 UNIVERSITY AVE
SAN DIEGO CA
92103-3398
US

IV. Provider business mailing address

1 CVS DR BOX 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 800-773-6408
  • Fax:
Mailing address:
  • Phone: 401-765-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHY49046
License Number State

VIII. Authorized Official

Name: SUSAN COLBERT
Title or Position: DIRECTOR PAYER RELATIONS
Credential:
Phone: 401-770-2751