Provider Demographics
NPI:1538527569
Name:PPG STORE 1 LLC
Entity type:Organization
Organization Name:PPG STORE 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER, RPH, AO
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:870-814-0605
Mailing Address - Street 1:PO BOX 8070
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-0001
Mailing Address - Country:US
Mailing Address - Phone:870-814-0605
Mailing Address - Fax:888-861-0863
Practice Address - Street 1:607 HIGHWAY 71 E STE B
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:AR
Practice Address - Zip Code:72944-3709
Practice Address - Country:US
Practice Address - Phone:479-269-6161
Practice Address - Fax:479-269-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR208303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158060OtherPK