Provider Demographics
NPI:1073579843
Name:MCCOY-TYGART DRUG STORE INC
Entity Type:Organization
Organization Name:MCCOY-TYGART DRUG STORE INC
Other - Org Name:MCCOY TYGART DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST,CORP.OFCER.
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:TYGART
Authorized Official - Suffix:
Authorized Official - Credentials:PD
Authorized Official - Phone:870-942-5121
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72150-0217
Mailing Address - Country:US
Mailing Address - Phone:870-942-5121
Mailing Address - Fax:870-942-2592
Practice Address - Street 1:821 N ROCK ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:AR
Practice Address - Zip Code:72150-7623
Practice Address - Country:US
Practice Address - Phone:870-942-5121
Practice Address - Fax:870-942-2592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR06048332B00000X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR100377407Medicaid
AR102512716Medicaid
AR0656110001Medicare NSC