Provider Demographics
NPI:1477625705
Name:OAK GROVE PHARMACY
Entity Type:Organization
Organization Name:OAK GROVE PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-264-1198
Mailing Address - Street 1:5039 OLD HIGHWAY 11
Mailing Address - Street 2:SUITE# 1
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8845
Mailing Address - Country:US
Mailing Address - Phone:601-264-1198
Mailing Address - Fax:601-264-1106
Practice Address - Street 1:5039 OLD HIGHWAY 11
Practice Address - Street 2:SUITE# 1
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39402-8845
Practice Address - Country:US
Practice Address - Phone:601-264-1198
Practice Address - Fax:601-264-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07555183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00030315Medicaid