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Missouri CVS Pharmacy LLC

Organization Active NPI Pharmacy · Jefferson City, MO

NPI 1194767384 · NPPES record last updated Nov 21, 2016

Key facts

NPI
1194767384
Entity type
Organization (NPI type 2)
Primary specialty
Pharmacy 333600000X
Legal business name
MISSOURI CVS PHARMACY LLC
Practice address
735 W Stadium Blvd
Jefferson City, MO 65109-4753
Phone
(573) 893-1079
Fax
(573) 658-9385
NPI assigned
Jun 12, 2006
Organization subpart
No

Authorized official

Name
Susan Colbert
Title
Sr. Director, Payer Relations
Phone
(401) 770-2751

Corporate family (same tax ID) 24

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

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

Laboratory certificates & supplier records

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

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
CVS Pharmacy #16228
735 W Stadium Blvd, Jefferson City, MO 65109-4753 · (573) 893-1079		 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
Participating since Jan 1, 2025

Medicare participation

Medicare fee-for-service enrollment
Enrolled (2 enrollments) in MO

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20061106000551 MO Part B Supplier - Mass Immunization (Roster Biller Only) 3577560499 This NPI is an additional NPI on the enrollment
O20161025002536 MO DME Supplier - Pharmacy 3577560499 Practice locations: Jefferson City, MO

National Provider Directory

Tax ID family
Missouri CVS Pharmacy LLC (196 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X Yes
Community/Retail Pharmacy 3336C0003X 2006020283 MO

Addresses

Primary practice location

735 W Stadium Blvd
Jefferson City, MO 65109-4753

Mailing address

1 CVS Dr
Box 1075
Woonsocket, RI 02895-6146
Phone (401) 765-1500

Other identifiers

IdentifierTypeStateIssuer
2049266OtherPK

Other names

  • CVS Pharmacy #16228 Doing business as

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Nov 21, 2016.

{
    "created_epoch": "1150070400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1479686400000",
    "number": "1194767384",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 CVS DR",
            "address_2": "BOX 1075",
            "city": "WOONSOCKET",
            "state": "RI",
            "postal_code": "028956146",
            "telephone_number": "401-765-1500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "735 W STADIUM BLVD",
            "city": "JEFFERSON CITY",
            "state": "MO",
            "postal_code": "651094753",
            "telephone_number": "573-893-1079",
            "fax_number": "573-658-9385"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSOURI CVS PHARMACY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-12",
        "last_updated": "2016-11-21",
        "status": "A",
        "authorized_official_last_name": "COLBERT",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "SR. DIRECTOR, PAYER RELATIONS",
        "authorized_official_telephone_number": "401-770-2751"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "MO",
            "license": "2006020283",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2049266",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CVS Pharmacy #16228",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Jefferson City, MO

All providers in Jefferson City, MO · Pharmacy in Missouri

Sources for this page

Verify at the official NPI Registry.