MEDICARE: WISCONSIN CVS PHARMACY 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	8879042	WI
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2116729	OTHER		PK

General Provider Information

NPI Number	:	1255589602
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISCONSIN CVS PHARMACY LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	MAIL CODE 1090
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-6146
Country	:	US
Telephone Number	:	401-765-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	9777 76TH ST
Second Line	:
City	:	PLEASANT PRAIRIE
State	:	WI
Zip	:	53158-1990
Country	:	US
Telephone Number	:	262-842-1171
Fax Number	:	262-842-1181

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

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	12/13/2016

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