Provider Demographics
NPI:1699229757
Name:OAKRIDGE COMMUNITY CARE HOME INC
Entity Type:Organization
Organization Name:OAKRIDGE COMMUNITY CARE HOME INC
Other - Org Name:OAKRIDGE CARE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-708-3477
Mailing Address - Street 1:2470 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-9276
Mailing Address - Country:US
Mailing Address - Phone:864-621-4958
Mailing Address - Fax:
Practice Address - Street 1:2470 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-9276
Practice Address - Country:US
Practice Address - Phone:864-708-3477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OAKRIDGE COMMUNITY CARE HOME INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-06
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC717512Medicaid