Provider Demographics
NPI:1801990692
Name:PENNSYLVANIA CVS PHARMACY L L C
Entity type:Organization
Organization Name:PENNSYLVANIA CVS PHARMACY L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR, DIRECTOR PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-770-2751
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 1:3811 NESHAMINY BLVD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-1650
Practice Address - Country:US
Practice Address - Phone:215-396-5690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
PAPP481539333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3985388OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3985388OtherOTHER ID NUMBER-COMMERCIAL NUMBER
5619370001Medicare NSC