MEDICARE: GRAND ST PAUL 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
1	3336C0003X	Community/Retail Pharmacy	11720	MN
2	332B00000X	Durable Medical Equipment & Medical Supplies
3	333600000X	Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2048308	OTHER		PK

General Provider Information

NPI Number	:	1952323644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRAND ST PAUL CVS 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	:	21615 S DIAMOND LAKE RD
Second Line	:
City	:	ROGERS
State	:	MN
Zip	:	55374-8893
Country	:	US
Telephone Number	:	763-428-6392
Fax Number	:	763-898-5508

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	:	11/15/2016

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