MEDICARE: HOLIDAY CVS 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	20230	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1055284	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164526133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLIDAY CVS 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	:	4120 HENDERSON BLVD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33629-5750
Country	:	US
Telephone Number	:	813-281-5353
Fax Number	:	813-281-5356

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

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	03/19/2012

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