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

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WD0400X	Diabetes Educator Registered Nurse
2	261QM2500X	Medical Specialty Clinic/Center
3	332B00000X	Durable Medical Equipment & Medical Supplies	005832	MO
4	333600000X	Pharmacy	005832	MO
5	3336C0003X	Community/Retail Pharmacy

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2629915	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1720016819
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI CVS PHARMACY, L.L.C.

Provider Business Mailing Address
First Line	:	1 CVS DR # 1075
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	:	1160 SHACKELFORD RD
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63031-4369
Country	:	US
Telephone Number	:	314-838-4660
Fax Number	:	314-838-4664

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

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	07/08/2020

1152 SHACKELFORD RD
FLORISSANT, MO
63031-4369

Practice Phone: 314-388-1530
Practice Fax: 314-388-1550