MEDICARE: KENTUCKY CVS PHARMACY, L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy	P06004	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1800487	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1023111762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENTUCKY CVS PHARMACY, L.L.C.

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	PO BOX 1075
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	3997 7TH STREET RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-4103
Country	:	US
Telephone Number	:	502-448-3383
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR, PAYER RELATIONS
Name	:	SUSAN F COLBERT
Credential	:
Telephone Number	:	401-770-2751

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	10/06/2010

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