=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487523049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CORNERSTONE PHARMACY CONWAY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2025
-----------------------------------------------------
Last Update Date | 11/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 HOGAN LN STE 10
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-7959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-328-3282
-----------------------------------------------------
Fax | 501-328-3278
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 815 HOGAN LN STE 10
-----------------------------------------------------
City | CONWAY
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72034-7959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-328-3282
-----------------------------------------------------
Fax | 501-328-3278
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOHN WIRGES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-328-3282
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------