Holiday CVS LLC

Primary specialty

PharmacyTaxonomy code 333600000X

License

20642 Issued in FL

Legal business name

HOLIDAY CVS LLC

Doing business as

CVS Pharmacy 05169

Practice address

100 2ND Ave SE
Jasper, FL 32052-6114

Phone

(386) 792-2551

Fax

(386) 792-3577

NPI assigned

Sep 12, 2006

Last updated

Nov 21, 2012By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Susan F Colbert

Title

Director Phcy Enrollments

Phone

(401) 770-2751

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• CVS PHARMACY 05169 Doing business as

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

• CVS Pharmacy Inc.

  dba CVS Pharmacy #17247

  • Pharmacy
  • North Dartmouth, MA
  • NPI 1831271071

  Member Of

  NPD member

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Keonjala Shanae Williams, PHARMD

  • Pharmacist
  • Jasper, FL
  • NPI 1760087738
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158019200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1353456000000",
    "number": "1114021078",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 CVS DR",
            "address_2": "PO BOX 1075",
            "city": "WOONSOCKET",
            "state": "RI",
            "postal_code": "028956146"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 2ND AVE SE",
            "city": "JASPER",
            "state": "FL",
            "postal_code": "320526114",
            "telephone_number": "386-792-2551",
            "fax_number": "386-792-3577"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOLIDAY CVS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-12",
        "last_updated": "2012-11-21",
        "status": "A",
        "authorized_official_last_name": "COLBERT",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "F",
        "authorized_official_title_or_position": "DIRECTOR PHCY ENROLLMENTS",
        "authorized_official_telephone_number": "401-770-2751"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": "FL",
            "license": "20642",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "1079171",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "105940800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CVS PHARMACY 05169",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Pharmacy in Jasper, FL
• Providers in Jasper, FL by specialty
• Pharmacy in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 21, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.