MEDICARE: GEORGIA CVS PHARMACY LLC

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	333600000X	Pharmacy	004641	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1116551	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1033212790
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA CVS PHARMACY LLC

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	:	546 BANKHEAD HWY
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-2463
Country	:	US
Telephone Number	:	770-834-1091
Fax Number	:

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

Provider Enumeration Date	:	09/07/2006
Last Update Date	:	03/07/2012

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