Provider Demographics
NPI:1124122023
Name:HOLIDAY CVS LLC
Entity type:Organization
Organization Name:HOLIDAY CVS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position: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:4010-770-2751
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:PO BOX 1075
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6800 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33405-4611
Practice Address - Country:US
Practice Address - Phone:561-586-4054
Practice Address - Fax:561-588-6316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 332B00000X
FL20471333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
1038694OtherOTHER ID NUMBER-COMMERCIAL NUMBER
FL105851700Medicaid
5140820448Medicare NSC
FL105851700Medicaid