MEDICARE: LONGS DRUG STORES CALIFORNIA, 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
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy	PHY-784

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1240477	OTHER		NCPDP - OTHER COMMERCIAL IDENTIFIER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023338720
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUG STORES CALIFORNIA, L.L.C.

Provider Business Mailing Address
First Line	:	BOX 1075
Second Line	:	ONE CVS DRIVE PHARMACY ENROLLMENTS
City	:	WOONSOCKET
State	:	RI
Zip	:	02895
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1130 KUALA ST
Second Line	:
City	:	PEARL CITY
State	:	HI
Zip	:	96782-2959
Country	:	US
Telephone Number	:	808-456-5302
Fax Number	:

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

Provider Enumeration Date	:	06/03/2010
Last Update Date	:	10/15/2010

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