Active NPI
Holiday CVS LLC
Doing business as CVS Pharmacy 04422
- Pharmacy
- Palatka, FL
National Provider Identifier
1477657328
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacy
- License
- 20567
- Legal business name
- HOLIDAY CVS LLC
- Doing business as
- CVS Pharmacy 04422
- Practice address
- 201 S State Road 19
Palatka, FL 32177-3937 - Phone
- (386) 325-7576
- Fax
- (904) 325-8195
- NPI assigned
- Sep 12, 2006
- Last updated
- Nov 15, 2012
- Organization subpart
- No
NPPES NPI Registry
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
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | 20567 | FL | Primary |
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
201 S State Road 19
Palatka, FL 32177-3937
Mailing address
1 CVS Dr
PO Box 1075
Woonsocket, RI 02895-6146
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 105555100 | Medicaid | FL | |
| 1064865 | Other | OTHER ID NUMBER-COMMERCIAL NUMBER |
Other names 1
- CVS PHARMACY 04422
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in FL
Enrollment records 2
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20081223000620 | FL | Part B Supplier - Mass Immunization (Roster Biller Only) | 2668534702 | This NPI is an additional NPI on the enrollment |
| O20100930042836 | FL | DME Supplier - Pharmacy | 2668534702 | Practice locations: Palatka, FL |
National Provider Directory
National Provider Directory- Tax ID family
- Holiday CVS
Organizations with this tax ID in the same state 24
This tax ID family is large, so up to 24 of its organizations in the same state are linked here.
Member of 1
Organizations this organization is a member of, according to the National Provider Directory.
Locations
201 S State Road 19
Palatka, FL 32177
Phone (386) 325-7576
Practitioners & affiliated clinicians
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.
-
- Pharmacist
- Jacksonville, FL
- NPI 1467055756
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1158019200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1352937600000",
"number": "1477657328",
"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": "201 S STATE ROAD 19",
"city": "PALATKA",
"state": "FL",
"postal_code": "321773937",
"telephone_number": "386-325-7576",
"fax_number": "904-325-8195"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "HOLIDAY CVS LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-09-12",
"last_updated": "2012-11-15",
"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": "20567",
"primary": true
},
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "105555100",
"state": "FL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "OTHER ID NUMBER-COMMERCIAL NUMBER",
"identifier": "1064865",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "CVS PHARMACY 04422",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Palatka, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2012; 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.