Healthcare Provider Details

I. General information

NPI: 1124179080
Provider Name (Legal Business Name): GEORGIA CVS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 S TALLAHASSEE ST
HAZLEHURST GA
31539-6157
US

IV. Provider business mailing address

1 CVS DR BOX 1075 - PHARMACY ENROLLMENTS
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 912-375-7729
  • Fax:
Mailing address:
  • Phone: 401-765-1500
  • Fax: 401-770-7108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberPHRE004803
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberPHRE004803
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateGA

VIII. Authorized Official

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