Provider Demographics
NPI:1386872604
Name:SOUTH CAROLINA CVS PHARMACY, L.L.C.
Entity type:Organization
Organization Name:SOUTH CAROLINA CVS PHARMACY, L.L.C.
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:401-765-1500
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:BOX 1075
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:401-735-1080
Practice Address - Street 1:101 FOUNDERS BAY RD
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-8089
Practice Address - Country:US
Practice Address - Phone:436-518-8638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC710531Medicaid
4228880OtherNCPDP
4228880OtherNCPDP
SC710531Medicaid
P00986712Medicare PIN