Healthcare Provider Details

I. General information

NPI: 1710080551
Provider Name (Legal Business Name): GEORGIA CVS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11685 COLUMBIA ST
BLAKELY GA
39823-2573
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 912-723-4271
  • Fax:
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 TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number005504
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000186711A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
Identifier1124623
Identifier TypeOTHER
Identifier State
Identifier IssuerOTHER ID NUMBER-COMMERCIAL NUMBER
# 3
Identifier1710080551
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 4
Identifier007902700
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

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