Healthcare Provider Details

I. General information

NPI: 1265813364
Provider Name (Legal Business Name): WISCONSIN CVS PHARMACY, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2015
Last Update Date: 11/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 N 14TH ST
SHEBOYGAN WI
53081-3213
US

IV. Provider business mailing address

BOX 1075 ONE CVS DRIVE
WOONSOCKET RI
02895-6146
US

V. Phone/Fax

Practice location:
  • Phone: 920-452-0079
  • 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 StateWI
# 2
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number StateWI

VIII. Authorized Official

Name: SUSAN COLBERT
Title or Position: SR. DIRECTOR-PAYER RELATIONS
Credential:
Phone: 401-765-1500