Provider Demographics
NPI:1124063144
Name:MISSOURI CVS PHARMACY, L.L.C.
Entity type:Organization
Organization Name:MISSOURI CVS PHARMACY, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR, PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
Mailing Address - Street 1:1 CVS DR # 1075
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:
Practice Address - Street 1:15425 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3077
Practice Address - Country:US
Practice Address - Phone:636-256-7922
Practice Address - Fax:636-256-6998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCHNUCK MARKETS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-17
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X, 163WD0400X, 3336C0003X
MO004766332B00000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes EducatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO602902504Medicaid
2624333OtherOTHER ID NUMBER-COMMERCIAL NUMBER