Healthcare Provider Details

I. General information

NPI: 1194748483
Provider Name (Legal Business Name): GRAND ST PAUL CVS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 COUNTY ROAD E E
VADNAIS HTS MN
55127-7114
US

IV. Provider business mailing address

1 CVS DR MAIL CODE 1090
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 651-483-2776
  • Fax: 651-234-4692
Mailing address:
  • Phone: 401-765-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number212388
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

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