=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790002921
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODWARD DETROIT CVS, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/28/2010
-----------------------------------------------------
Last Update Date | 02/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5449 JACKSON RD,
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 737-332-3872
-----------------------------------------------------
Fax | 401-770-7108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 CVS DR
-----------------------------------------------------
City | WOONSOCKET
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02895-6146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-765-1500
-----------------------------------------------------
Fax | 401-770-7108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR, PAYER RELATIONS
-----------------------------------------------------
Name | SUSAN F. COLBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 401-765-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------