MEDICARE: LONGS DRUG STORES CALIFORNIA 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	PHY49696	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0591998	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538101365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LONGS DRUG STORES CALIFORNIA LLC

Provider Business Mailing Address
First Line	:	1 CVS DR
Second Line	:	P.O. BOX 1075
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	:	5170 MOORPARK AVE
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95129-2139
Country	:	US
Telephone Number	:	408-257-9918
Fax Number	:	408-257-4504

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

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	08/23/2011

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