Basic Information
| Provider Information | |||||||||
| NPI: | 1669664793 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GERMAN DOBSON CVS, L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE CVS DRIVE | ||||||||
| Address2: | |||||||||
| City: | WOONSOCEKT | ||||||||
| State: | RI | ||||||||
| PostalCode: | 02895 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 21201 E OCOTILLO RD | ||||||||
| Address2: | |||||||||
| City: | QUEEN CREEK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 851429339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809871615 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 01/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 333600000X | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 280046 | 05 | AZ | MEDICAID | P00959043 | 01 | RR PTAN | OTHER |