Highland Park CVS, L.L.C.
Organization Active NPI Pharmacy · Peoria, IL
NPI 1104929876 · NPPES record last updated Mar 13, 2012
Key facts
- NPI
- 1104929876
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pharmacy 333600000X
- License
- 054-011784 (IL)
- Legal business name
- HIGHLAND PARK CVS, L.L.C.
- Practice address
- 200 N Main St
Peoria, IL 61611-2549 - Phone
- (309) 694-1496
- NPI assigned
- Sep 7, 2006
- Organization subpart
- No
Authorized official
- Name
- Susan Colbert
- Title
- Director
- Phone
- (401) 765-1500
Corporate family (same tax ID) 24
Member of 1
Laboratory certificates & supplier records
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| CVS Pharmacy #06453 |
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… | Accepts assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in IL
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20080103000235 | IL | Part B Supplier - Mass Immunization (Roster Biller Only) | 2860572856 | This NPI is an additional NPI on the enrollment |
| O20100930074513 | IL | DME Supplier - Pharmacy | 2860572856 | Practice locations: East Peoria, IL |
National Provider Directory
- Tax ID family
- Highland Park CVS LLC
Locations
200 N Main St
Peoria, IL 61611
Phone (309) 694-1496
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | 054-011784 | IL | Yes |
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
200 N Main St
Peoria, IL 61611-2549
Mailing address
1 CVS Dr
PO Box 1075
Woonsocket, RI 02895-6146
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1448198 | Other | OTHER ID NUMBER-COMMERCIAL NUMBER |
Other names
- CVS PHARMACY 06453
Other providers in Peoria, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 13, 2012. 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.