Healthcare Provider Details

I. General information

NPI: 1922034446
Provider Name (Legal Business Name): MISSOURI CVS PHARMACY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6920 OLIVE BLVD
SAINT LOUIS MO
63130-2516
US

IV. Provider business mailing address

1 CVS DRIVE BOX 1075
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 314-721-3276
  • Fax: 314-721-4394
Mailing address:
  • Phone: 401-765-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number006308
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number006308
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

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