Provider Demographics
NPI:1669835484
Name:PPG STORE 3, LLC
Entity Type:Organization
Organization Name:PPG STORE 3, LLC
Other - Org Name:CORNERSTONE PHARMACY MARKHAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, AO
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLDERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:870-814-0605
Mailing Address - Street 1:11414 W MARKHAM STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72703
Mailing Address - Country:US
Mailing Address - Phone:501-904-4299
Mailing Address - Fax:501-904-4298
Practice Address - Street 1:11414 W MARKHAM STREET
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72703
Practice Address - Country:US
Practice Address - Phone:501-904-4299
Practice Address - Fax:501-904-4298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
ARAR208403336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2159147OtherPK
AR7545420001Medicare NSC