=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912257254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CVS PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 09/13/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 FETLOCK DR
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 28588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-236-6300
-----------------------------------------------------
Fax | 843-236-6335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 FETLOCK DR
-----------------------------------------------------
City | MYRTLE BEACH
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 28588
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-236-6300
-----------------------------------------------------
Fax | 843-236-6335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STAFF PHARMACIST
-----------------------------------------------------
Name | LAWRENCE JOHN MAIOLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 843-236-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 12794
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------