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NPI Code Detail

MEDICARE: HIGHLAND PARK CVS LLC

MEDICARE: HIGHLAND PARK 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
1332B00000XDurable Medical Equipment & Medical Supplies
23336C0003XCommunity/Retail Pharmacy
3333600000XPharmacy

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11482152OTHERNCPDP

General Provider Information

NPI Number : 1174786354
Entity Type Code : Organization
Provider Name (Legal Business Name) : HIGHLAND PARK CVS LLC
Provider Business Mailing Address
First Line : 1 CVS DR
Second Line : BOX 1075- PHARMACY ENROLLMENTS
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 : 5205 N BROADWAY ST
Second Line :
City : CHICAGO
State : IL
Zip : 60640-2303
Country : US
Telephone Number : 773-275-5641
Fax Number :
Authorized Official
Title or Position : MGR PHCY ENROLLMENTS
Name : CRISTIANA MAURICIO
Credential :
Telephone Number : 401-765-1500
Provider Enumeration Date : 07/08/2008
Last Update Date : 10/08/2014

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