Healthcare Provider Details

I. General information

NPI: 1124235916
Provider Name (Legal Business Name): WISCONSIN CVS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 LIEN RD
MADISON WI
53704-3608
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 608-819-1911
  • Fax: 608-327-5671
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 TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number8749042
License Number StateWI

VIII. Authorized Official

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