Healthcare Provider Details

I. General information

NPI: 1861740615
Provider Name (Legal Business Name): KENTUCKY CVS PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MAIN ST
BENTON KY
42025-1119
US

IV. Provider business mailing address

1 CVS DR
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-8636
  • 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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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