Missouri CVS Pharmacy LLC
Organization Active NPI Pharmacy · O'Fallon, MO
NPI 1811365257 · NPPES record last updated Jan 13, 2016
Key facts
- NPI
- 1811365257
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Pharmacy 333600000X
- Legal business name
- MISSOURI CVS PHARMACY LLC
- Practice address
- 1589 Bryan Rd
O'Fallon, MO 63366-3709 - Phone
- (636) 281-0189
- NPI assigned
- Sep 2, 2015
- Organization subpart
- No
Authorized official
- Name
- Susan Colbert
- Title
- Director
- Phone
- (401) 765-1500
Corporate family (same tax ID) 24
Member of 1
Practitioners 1
-
Xavier Collman, RPH
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in MO
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20061106000551 | MO | Part B Supplier - Mass Immunization (Roster Biller Only) | 3577560499 | This NPI is an additional NPI on the enrollment |
| O20160104000200 | MO | DME Supplier - Pharmacy | 3577560499 | Practice locations: O Fallon, MO |
National Provider Directory
- Tax ID family
- Missouri CVS Pharmacy LLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | Yes | ||
| Community/Retail Pharmacy | 3336C0003X |
Addresses
Primary practice location
1589 Bryan Rd
O'Fallon, MO 63366-3709
Mailing address
1 CVS Dr
Woonsocket, RI 02895-6146
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 2642824 | Other | MO | NCPDP |
| 1811365257 | Medicaid | MO |
Other names
- CVS Pharmacy# 10546
Other providers in O'Fallon, MO
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 13, 2016. 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.