Healthcare Provider Details

I. General information

NPI: 1639105984
Provider Name (Legal Business Name): HIGHLAND PARK CVS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MADISON AVE
GRANITE CITY IL
62040-3651
US

IV. Provider business mailing address

1 CVS DR # 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 618-451-0521
  • Fax: 314-231-1918
Mailing address:
  • Phone: 401-765-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number05412052
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number05412052
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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