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NPI Code Detail

MEDICARE: HOLIDAY CVS LLC

MEDICARE: HOLIDAY CVS 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
1332B00000XDurable Medical Equipment & Medical Supplies
23336C0003XCommunity/Retail PharmacyPH 29681FL
3333600000XPharmacy

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12011790OTHERPK

General Provider Information

NPI Number : 1912929530
Entity Type Code : Organization
Provider Name (Legal Business Name) : HOLIDAY CVS LLC
Provider Business Mailing Address
First Line : 1 CVS DR
Second Line : BOX 1075
City : WOONSOCKET
State : RI
Zip : 02895-6146
Country : US
Telephone Number : 401-765-1500
Fax Number :
Provider Business Practice Location Address
First Line : 4155 W LAKE MARY BLVD
Second Line :
City : LAKE MARY
State : FL
Zip : 32746-2410
Country : US
Telephone Number : 407-330-9190
Fax Number : 407-547-3513
Authorized Official
Title or Position : SR. DIRECTOR, PAYER RELATIONS
Name : SUSAN COLBERT
Credential :
Telephone Number : 401-770-2751
Provider Enumeration Date : 07/24/2006
Last Update Date : 09/22/2016

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