Provider Demographics
NPI:1568590321
Name:OAK PLACE PHARMACY
Entity Type:Organization
Organization Name:OAK PLACE PHARMACY
Other - Org Name:OAK PLACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:RALEY
Authorized Official - Suffix:SR
Authorized Official - Credentials:REG PHARMACIST
Authorized Official - Phone:228-864-6647
Mailing Address - Street 1:1311 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2419
Mailing Address - Country:US
Mailing Address - Phone:228-864-6647
Mailing Address - Fax:228-864-6698
Practice Address - Street 1:1311 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2419
Practice Address - Country:US
Practice Address - Phone:228-864-6647
Practice Address - Fax:228-864-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0106201.1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00092053Medicaid
2508414OtherNABP