MEDICARE: PPG STORE 6 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	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	AR20873	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2174625	OTHER		PK

General Provider Information

NPI Number	:	1013422179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PPG STORE 6 LLC

Provider Business Mailing Address
First Line	:	824 SALEM RD
Second Line	:	STE 210
City	:	CONWAY
State	:	AR
Zip	:	72034-4821
Country	:	US
Telephone Number	:	501-450-0000
Fax Number	:	501-450-6433

Provider Business Practice Location Address
First Line	:	2235 DAVE WARD DR STE 108
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-7040
Country	:	US
Telephone Number	:	501-450-0000
Fax Number	:	501-450-6433

Authorized Official
Title or Position	:	PARTNER/AO
Name	:	ZACH HOLDERFIELD
Credential	:
Telephone Number	:	870-814-0605

Provider Enumeration Date	:	12/11/2017
Last Update Date	:	04/18/2018

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Directions to “PPG STORE 6 LLC ” Practice Location

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