Grand St Paul CVS LLC
Organization Active NPI Pharmacy · Otsego, MN
NPI 1023030707 · NPPES record last updated Nov 21, 2016
Key facts
- NPI
- 1023030707
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pharmacy 333600000X
- Legal business name
- GRAND ST PAUL CVS LLC
- Practice address
- 15800 87TH St NE
Otsego, MN 55330-6546 - Phone
- (763) 252-1316
- Fax
- (763) 252-1326
- NPI assigned
- Jul 24, 2006
- Organization subpart
- No
Authorized official
- Name
- Susan Colbert
- Title
- Sr. Director, Payer Relations
- Phone
- (401) 770-2751
Corporate family (same tax ID) 14
Member of 1
Laboratory certificates & supplier records
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| CVS Pharmacy #17509 |
Immunosuppressive Drugs|Infusion Drugs|Nebulizer Drugs|Oral Anticancer Drugs|Oral Antiemetic Drugs|Commodes, Urinals, Bedpans|Blood Glucose Monitors/Supplies (Non-Mail Order)|Blood Glucose Monitors/Supplies (Mail Order)|Heat & Cold Applications|Canes and/or Crutches|Walkers|Ostomy Supplies|Urologic… | Does not accept assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MN
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20101103001135 | MN | Part B Supplier - Mass Immunization (Roster Biller Only) | 4688875156 | This NPI is an additional NPI on the enrollment |
| O20161024001077 | MN | DME Supplier - Pharmacy | 4688875156 | Practice locations: Otsego, MN |
National Provider Directory
- Tax ID family
- Grand St Paul CVS Stores LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | Yes | ||
| Community/Retail Pharmacy | 3336C0003X | 263238 | MN |
Addresses
Primary practice location
15800 87TH St NE
Otsego, MN 55330-6546
Mailing address
1 CVS Dr
Mail Code 1090
Woonsocket, RI 02895-6146
Phone (401) 765-1500
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 001178900 | Medicaid | MN | |
| 2047383 | Other | PK |
Other names
- CVS Pharmacy #17509
Other providers in Otsego, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Nov 21, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.