Healthcare Provider Details

I. General information

NPI: 1780147504
Provider Name (Legal Business Name): CHERRY GROVE COMPOUNDING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124-2 SEA MOUNTAIN HIGHWAY
NORTH MYRTLE BEACH SC
29582
US

IV. Provider business mailing address

1201 SEA MOUNTAIN HWY
NORTH MYRTLE BEACH SC
29582-2216
US

V. Phone/Fax

Practice location:
  • Phone: 843-361-3784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JENNA L DUKES
Title or Position: OWNER
Credential: PHARMD
Phone: 843-361-3784