Healthcare Provider Details

I. General information

NPI: 1669656864
Provider Name (Legal Business Name): PENNSYLVANIA CVS PHARMACY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5703 STEUBENVILLE PIKE
MC KEES ROCKS PA
15136-1310
US

IV. Provider business mailing address

1 CVS DR BOX 1075 - PHARMACY ENROLLMENTS
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 412-788-4676
  • Fax:
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 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
Identifier3989590
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerCOMMERCIAL NUMBER
# 2
Identifier1015538870020
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

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