MEDICARE: CHERRY GROVE DRUG LLC

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1477072874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERRY GROVE DRUG LLC

Provider Business Mailing Address
First Line	:	1201 SEA MOUNTAIN HWY
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-2216
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 SEA MOUNTAIN HWY
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582
Country	:	US
Telephone Number	:	843-361-3784
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JENNA LYNNE DUKES
Credential	:	PHARMD
Telephone Number	:	843-361-3784

Provider Enumeration Date	:	09/18/2017
Last Update Date	:	06/21/2018

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