Highland Park CVS, L.L.C.
Organization Active NPI Pharmacy · O Fallon, IL
NPI 1245309194 · NPPES record last updated Jul 15, 2020
Key facts
- NPI
- 1245309194
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pharmacy 333600000X
- License
- 54013333 (IL)
- Legal business name
- HIGHLAND PARK CVS, L.L.C.
- Practice address
- 907 E US Highway 50
O Fallon, IL 62269-2856 - Phone
- (618) 632-5525
- Fax
- (618) 632-0729
- NPI assigned
- Nov 7, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- SCHNUCK MARKETS INC
Authorized official
- Name
- Susan Colbert
- Title
- Sr. Director, Payer Relations
- Phone
- (401) 770-2751
Parent organization (reported in NPPES) 1
Corporate family (same tax ID) 24
Member of 1
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 |
| O20200915002470 | IL | DME Supplier - Pharmacy | 2860572856 | Practice locations: O Fallon, IL |
National Provider Directory
- Tax ID family
- Highland Park CVS LLC
- Part of
- Schnucks Pharmacy 711
Locations
907 E Highway 50
O Fallon, IL 62269
Phone (618) 632-5525
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Diabetes Educator Registered Nurse |
163WD0400X | |||
| Medical Specialty Clinic/Center | 261QM2500X | |||
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | 54013333 | IL | Yes |
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
907 E US Highway 50
O Fallon, IL 62269-2856
Mailing address
1 CVS Drive
Box 1075
Woonsocket, RI 02895-6146
Phone (401) 765-1500
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 431394080001 | Medicaid | IL | |
| 1467275 | Other | OTHER ID NUMBER-COMMERCIAL NUMBER |
Other names
- CVS Pharmacy #18038
Other providers in O Fallon, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 15, 2020. 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.