Healthcare Provider Details

I. General information

NPI: 1124127436
Provider Name (Legal Business Name): MISSOURI CVS PHARMACY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7107 N OAK TRFY
GLADSTONE MO
64118-2514
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 816-436-3200
  • Fax: 816-468-6269
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number2004023149
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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