=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497297758
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CVS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2016
-----------------------------------------------------
Last Update Date | 11/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 S KINGS HWY
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29577-4409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-448-1684
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 PALLADIUM DR
-----------------------------------------------------
City | SURFSIDE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29575-4780
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-554-4347
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACIST
-----------------------------------------------------
Name | DAISY REEVES
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 316-554-4347
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 36915
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------