Healthcare Provider Details

I. General information

NPI: 1285737957
Provider Name (Legal Business Name): HIGHLAND PARK CVS, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 03/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 B EASTWOOD DRIVE
MAHOMET IL
61853
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 217-586-2137
  • 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 TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number054-011844
License Number StateIL

VIII. Authorized Official

Name: SUSAN COLBERT
Title or Position: DIRECTOR
Credential:
Phone: 401-765-1500