MEDICARE: GRAND ST PAUL CVS LLC

Medicare Provider Information

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

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

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2430659	OTHER	MN	NCPDP

NPI Number	:	1225336894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND ST PAUL CVS LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:
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	:	4656 EXCELSIOR BLVD
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4938
Country	:	US
Telephone Number	:	952-929-0140
Fax Number	:	401-770-7108

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

Provider Enumeration Date	:	03/07/2011
Last Update Date	:	07/12/2011

4656 EXCELSIOR BLVD
ST LOUIS PARK, MN
55416-4938

Practice Phone: 952-929-0140
Practice Fax: 952-926-1055

4656 EXCELSIOR BLVD
ST LOUIS PARK, MN
55416-4938