=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467559948
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUISIANA CVS PHARMACY, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2006
-----------------------------------------------------
Last Update Date | 11/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 WEST PINE
-----------------------------------------------------
City | PONCHATOULA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-386-6132
-----------------------------------------------------
Fax | 985-370-6908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CVS DR PO BOX 1075
-----------------------------------------------------
City | WOONSOCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02895-6146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-765-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, PAYER RELATIONS
-----------------------------------------------------
Name | SUSAN COLBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-770-2751
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 5806
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------