Healthcare Provider Details

I. General information

NPI: 1518042688
Provider Name (Legal Business Name): HIGHLAND PARK CVS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 S BROADWAY STREET
COAL CITY IL
60416
US

IV. Provider business mailing address

1 CVS DRIVE BOX 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-0455
  • Fax: 815-634-4328
Mailing address:
  • Phone: 401-765-1500
  • Fax: 815-458-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203000679
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number054-008392
License Number StateIL

VIII. Authorized Official

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