Healthcare Provider Details

I. General information

NPI: 1336181528
Provider Name (Legal Business Name): HIGHLAND PARK CVS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 N 2ND ST
MACHESNEY PARK IL
61115-2405
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 815-636-2949
  • Fax:
Mailing address:
  • Phone:
  • 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 Number
License Number State

VIII. Authorized Official

Name: CRISTIANA MAURICIO
Title or Position: MANAGER PHARMACY ENROLLMENTS
Credential:
Phone: 401-770-2937