Healthcare Provider Details

I. General information

NPI: 1467874404
Provider Name (Legal Business Name): MISSOURI CVS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 03/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3603 MCMASTERS AVE
HANNIBAL MO
63401-2541
US

IV. Provider business mailing address

1 CVS DR
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 573-719-3122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1467874404
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier2641567
Identifier TypeOTHER
Identifier State
Identifier IssuerNCPDP

VIII. Authorized Official

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