Basic Information
| Provider Information | |||||||||
| NPI: | 1700011962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CVS ALBANY LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CVS PHARMACY# 06066 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CVS DR | ||||||||
| Address2: | BOX 1075- PHARMACY ENROLLMENTS | ||||||||
| City: | WOONSOCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028956146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017651500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2495 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127872194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLBERT | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, PAYER RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4017702751 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 03156847 | 05 | NY | MEDICAID | 3360966 | 01 | NCPDP | OTHER |