MEDICARE: GEORGIA CVS PHARMACY, L.L.C.

Medicare Provider Information

Scope of Practice

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

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1159955	OTHER	GA	NCPDP
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245550417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA CVS PHARMACY, L.L.C.

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	:

Provider Business Practice Location Address
First Line	:	680 PONCE DE LEON AVE.
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30308-1808
Country	:	US
Telephone Number	:	404-892-1164
Fax Number	:

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

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	06/04/2014

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