MEDICARE: MISSOURI CVS PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2641389	OTHER		NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184058240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI CVS PHARMACY LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3925 LINDELL BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-3203
Country	:	US
Telephone Number	:	314-535-1048
Fax Number	:

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

Provider Enumeration Date	:	08/26/2013
Last Update Date	:	11/21/2013

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