MEDICARE: OAK GROVE PHARMACY INC

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	AR10174	AR

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	2125605	OTHER		PK

General Provider Information

NPI Number	:	1316922487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAK GROVE PHARMACY INC

Provider Business Mailing Address
First Line	:	11114 MAC ARTHUR DR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72118-1854
Country	:	US
Telephone Number	:	501-851-3636
Fax Number	:	501-851-3640

Provider Business Practice Location Address
First Line	:	11114 MAC ARTHUR DR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72118-1854
Country	:	US
Telephone Number	:	501-851-3636
Fax Number	:	501-851-3640

Authorized Official
Title or Position	:	PHARMACIST/OWNER
Name	:	JACOB HYATT
Credential	:
Telephone Number	:	501-851-3636

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	01/06/2021

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