Provider Demographics
NPI:1003903204
Name:PLEASANT GROVE PHARMACY
Entity Type:Organization
Organization Name:PLEASANT GROVE PHARMACY
Other - Org Name:PLEASANT GROVE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEEPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-832-4545
Mailing Address - Street 1:3302 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0703
Mailing Address - Country:US
Mailing Address - Phone:903-832-4545
Mailing Address - Fax:903-832-4546
Practice Address - Street 1:3302 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0703
Practice Address - Country:US
Practice Address - Phone:903-832-4545
Practice Address - Fax:903-832-4546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX110563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX142931Medicaid
2102791OtherPK