NPIMap

Organization Active NPI

Mississippi CVS Pharmacy, L.L.C.

Doing business as CVS Pharmacy # 05883

  • Pharmacy
  • Kosciusko, MS
National Provider Identifier
1316046626
Registry record updated Jan 17, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
PharmacyTaxonomy code 333600000X
License
02212/01.2 Issued in MS
Legal business name
MISSISSIPPI CVS PHARMACY, L.L.C.
Doing business as
CVS Pharmacy # 05883
Practice address
108 Highway 12 E
Kosciusko, MS 39090-3304
Phone
(662) 289-1963
Fax
(662) 289-7375
NPI assigned
Sep 22, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 17, 2023

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

Authorized official

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

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Durable Medical Equipment & Medical Supplies 332B00000X
Pharmacy 333600000X 02212/01.2 MS Primary
Community/Retail Pharmacy 3336C0003X

Addresses

Primary practice location

108 Highway 12 E
Kosciusko, MS 39090-3304

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
2516586OtherOTHER ID NUMBER-COMMERCIAL NUMBER
000330350MedicaidMS

Other names 1

  • CVS PHARMACY # 05883 Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
CONNECT URL https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service Other ABILITY Network

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MS2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20100930007581 MS DME Supplier - Pharmacy 9335344456 Practice locations: Kosciusko, MS
O20101230001038 MS Part B Supplier - Mass Immunization (Roster Biller Only) 9335344456 This NPI is an additional NPI on the enrollment
Practice locations: Picayune, MS; Pascagoula, MS; Oxford, MS; Olive Branch, MS; Ocean Springs, MS; Natchez, MS; Laurel, MS; Meridian, MS…

National Provider Directory

National Provider Directory
Tax ID family
Mississippi CVS Pharmacy LLC48 organizations share this tax ID, including this one

Other organizations with this tax ID 47

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

View all 47

Member of 1

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

Locations

160 Highway 12 W
Kosciusko, MS 39090

108 Highway 12 E
Kosciusko, MS 39090
Phone (662) 289-1963

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1158883200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1673913600000",
    "number": "1316046626",
    "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",
            "telephone_number": "401-765-1500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "108 HIGHWAY 12 E",
            "city": "KOSCIUSKO",
            "state": "MS",
            "postal_code": "390903304",
            "telephone_number": "662-289-1963",
            "fax_number": "662-289-7375"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MISSISSIPPI CVS PHARMACY, L.L.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-22",
        "last_updated": "2023-01-17",
        "certification_date": "2023-01-17",
        "status": "A",
        "authorized_official_last_name": "COLBERT",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_title_or_position": "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": "MS",
            "license": "02212/01.2",
            "primary": true
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
            "identifier": "2516586",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "000330350",
            "state": "MS"
        }
    ],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "https://esmd.abilitynetwork.com:8291/Gateway/DocumentSubmission/2_0/NhinService/XDRRequest_Service",
            "affiliation": "Y",
            "endpointDescription": "2.16.840.1.113883.3.667.2",
            "affiliationName": "ABILITY Network",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "CMS esMD eMDR",
            "address_1": "100 N 6th St Ste 900A",
            "city": "Minneapolis",
            "state": "MN",
            "country_code": "US",
            "postal_code": "554031516",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "CVS PHARMACY # 05883",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "CVS PHARMACY # 05883",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Kosciusko, MS

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 17, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.