Healthcare Provider Details

I. General information

NPI: 1073579843
Provider Name (Legal Business Name): MCCOY-TYGART DRUG STORE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N ROCK ST
SHERIDAN AR
72150-7623
US

IV. Provider business mailing address

PO BOX 217
SHERIDAN AR
72150-0217
US

V. Phone/Fax

Practice location:
  • Phone: 870-942-5121
  • Fax: 870-942-2592
Mailing address:
  • Phone: 870-942-5121
  • Fax: 870-942-2592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberAR06048
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberAR06048
License Number StateAR

VIII. Authorized Official

Name: MR. PHILLIP A TYGART
Title or Position: PHARMACIST,CORP.OFCER.
Credential: P.D.
Phone: 870-942-5121