Healthcare Provider Details

I. General information

NPI: 1396849253
Provider Name (Legal Business Name): HOLIDAY CVS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E MAIN ST
LAKE BUTLER FL
32054-1360
US

IV. Provider business mailing address

1 CVS DR PO BOX 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-1685
  • Fax: 386-496-0753
Mailing address:
  • Phone: 401-765-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number20641
License Number StateFL

VIII. Authorized Official

Name: SUSAN F COLBERT
Title or Position: DIRECTOR . PHCY ENROLLMENTS
Credential:
Phone: 401-770-2751