Provider Demographics
NPI:1689113136
Name:PPG STORE 5, LLC
Entity Type:Organization
Organization Name:PPG STORE 5, LLC
Other - Org Name:HEARTLAND PHARMACY CABOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
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:501-941-4400
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:
Mailing Address - Fax:
Practice Address - Street 1:2006 S PINE ST
Practice Address - Street 2:SUITE F
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-9386
Practice Address - Country:US
Practice Address - Phone:501-941-4400
Practice Address - Fax:501-941-4430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy