Active NPI
Holiday CVS LLC
Doing business as CVS Pharmacy #05194
- Pharmacy
- Fort Walton Beach, FL
National Provider Identifier
1710081682
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacy
- License
- 20534
- Legal business name
- HOLIDAY CVS LLC
- Doing business as
- CVS Pharmacy #05194
- Practice address
- 1081 Beal Pkwy NW
Fort Walton Beach, FL 32547-1439 - Phone
- (850) 863-4400
- Fax
- (850) 863-4445
- NPI assigned
- Sep 12, 2006
- Last updated
- Dec 4, 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
- Patricia Vanderbrug
- Title
- Phcy Enrollments Representative
- Phone
- (401) 770-1624
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacy | 333600000X | 20534 | FL | Primary |
| Community/Retail Pharmacy | 3336C0003X | NU |
Addresses
Primary practice location
1081 Beal Pkwy NW
Fort Walton Beach, FL 32547-1439
Mailing address
1 CVS Dr
PO Box 1075
Woonsocket, RI 02895-6146
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1086695 | Other | OTHER ID NUMBER-COMMERCIAL NUMBER | |
| 021527900 | Medicaid | FL |
Other names 1
- CVS PHARMACY #05194
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 |
| O20100930071446 | FL | DME Supplier - Pharmacy | 2668534702 | Practice locations: Fort Walton Beach, FL |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 10D2221860 | Holiday CVS LLC Dba CVS/Pharmacy #5194 | Certificate of waiver | Apr 25, 2027 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Holiday CVS LLC | 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 |
National Provider Directory
National Provider Directory- Tax ID family
- Holiday CVS LLC
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
1081 Beal Pkwy N
Fort Walton Beach, FL 32547
Phone (850) 863-4400
Practitioners & affiliated clinicians
Practitioners 2
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
- Fort Walton Beach, FL
- NPI 1437753399
-
- Pharmacist
- Fort Walton Beach, FL
- NPI 1467081018
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": "1354579200000",
"number": "1710081682",
"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": "1081 BEAL PKWY NW",
"city": "FORT WALTON BEACH",
"state": "FL",
"postal_code": "325471439",
"telephone_number": "850-863-4400",
"fax_number": "850-863-4445"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "HOLIDAY CVS LLC",
"organizational_subpart": "NO",
"enumeration_date": "2006-09-12",
"last_updated": "2012-12-04",
"status": "A",
"authorized_official_last_name": "VANDERBRUG",
"authorized_official_first_name": "PATRICIA",
"authorized_official_title_or_position": "PHCY ENROLLMENTS REPRESENTATIVE",
"authorized_official_telephone_number": "401-770-1624"
},
"taxonomies": [
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": "FL",
"license": "20534",
"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": "1086695",
"state": null
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "021527900",
"state": "FL"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "CVS PHARMACY #05194",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Fort Walton Beach, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 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.