Provider Demographics
NPI:1336150911
Name:OAK GROVE PHARMACY INC
Entity Type:Organization
Organization Name:OAK GROVE PHARMACY INC
Other - Org Name:1750 MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PADELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-692-1686
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94011-1038
Mailing Address - Country:US
Mailing Address - Phone:650-692-1686
Mailing Address - Fax:650-692-0859
Practice Address - Street 1:1750 EL CAMINO REAL STE 101
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3210
Practice Address - Country:US
Practice Address - Phone:650-692-1686
Practice Address - Fax:650-692-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY474873336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2033127OtherPK
CAPHA19638Medicaid