MEDICARE: PLEASANT GROVE PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	11056	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2102791	OTHER		PK

General Provider Information

NPI Number	:	1003903204
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLEASANT GROVE PHARMACY

Provider Business Mailing Address
First Line	:	3302 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0703
Country	:	US
Telephone Number	:	903-832-4545
Fax Number	:	903-832-4546

Provider Business Practice Location Address
First Line	:	3302 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0703
Country	:	US
Telephone Number	:	903-832-4545
Fax Number	:	903-832-4546

Authorized Official
Title or Position	:	OWNER AND PHARMACIST
Name	:	MARCIA PEEPLES
Credential	:
Telephone Number	:	903-832-4545

Provider Enumeration Date	:	10/07/2006
Last Update Date	:	12/26/2014

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Directions to “PLEASANT GROVE PHARMACY ” Practice Location

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