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General NPI Number Information
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NPI Number | 1114021078
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Entity Type | Organization
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Legal Business Name | HOLIDAY CVS LLC
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Dates
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Enumeration Date | 09/12/2006
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 100 2ND AVE SE
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City | JASPER
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State | FL
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Zip | 32052-6114
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Country | US
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Telephone | 386-792-2551
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Fax | 386-792-3577
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Provider Business Mailing Address
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Address Line | 1 CVS DR PO BOX 1075
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City | WOONSOCKET
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State | RI
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Zip | 02895-6146
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR PHCY ENROLLMENTS
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Name | SUSAN F COLBERT
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Credential |
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Telephone | 401-770-2751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 20642
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License Number State | FL
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