MEDICARE: CVS STATE CAPITAL 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	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy	PH50000166	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2002943	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1063516987
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CVS STATE CAPITAL 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	770 ROOSEVELT TRL
Second Line	:
City	:	WINDHAM
State	:	ME
Zip	:	04062-5300
Country	:	US
Telephone Number	:	207-892-2541
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	SUSAN COLBERT
Credential	:
Telephone Number	:	401-765-1500

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	07/27/2010

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Directions to “CVS STATE CAPITAL LLC ” Practice Location

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