Provider Demographics
NPI:1447619572
Name:PPG STORE 2 LLC
Entity Type:Organization
Organization Name:PPG STORE 2 LLC
Other - Org Name:CORNERSTONE PHARMACY GENTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PIC, AO
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
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:479-525-6200
Mailing Address - Fax:888-861-0863
Practice Address - Street 1:560 GENTRY BLVD
Practice Address - Street 2:
Practice Address - City:GENTRY
Practice Address - State:AR
Practice Address - Zip Code:72734-8576
Practice Address - Country:US
Practice Address - Phone:479-525-6200
Practice Address - Fax:479-525-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-17
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ARAR208333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2158041OtherPK