Provider Demographics
NPI:1144488750
Name:HIGHLAND PARK CVS LLC
Entity type:Organization
Organization Name:HIGHLAND PARK CVS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR PHCY ENROLLMENTS
Authorized Official - Prefix:
Authorized Official - First Name:CRISTIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAURICIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-765-1500
Mailing Address - Street 1:BOX 1075 PHARMACY ENROLLMENTS
Mailing Address - Street 2:1 CVS DR
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:401-765-1500
Mailing Address - Fax:401-770-7108
Practice Address - Street 1:2250 41ST ST
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-736-7182
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1482013OtherNCPDP
IL=========015Medicaid
215982Medicare PIN
ILP00754411Medicare PIN
IL1482013OtherNCPDP