MEDICARE: LONGS DRUG STORES CALIFORNIA 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	PHY49395	CA
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0507787	OTHER	OTHER ID NUMBER-COMMERCIAL NUMBER
3	0507787	OTHER	OTHER ID NUMBER

General Provider Information

NPI Number	:	1104869437
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUG STORES CALIFORNIA LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	P.O. BOX 1075
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:	401-770-7108

Provider Business Practice Location Address
First Line	:	4445 MISSION BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92109-3919
Country	:	US
Telephone Number	:	858-273-0900
Fax Number	:	858-273-2254

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	08/23/2011

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Directions to “LONGS DRUG STORES CALIFORNIA LLC ” Practice Location

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