Provider Demographics
NPI:1013422179
Name:PPG STORE 6 LLC
Entity Type:Organization
Organization Name:PPG STORE 6 LLC
Other - Org Name:HEARTLAND PHARMACY CONWAY
Other - Org Type:Other Name
Authorized Official - Title/Position:PARTNER/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 1:824 SALEM RD
Mailing Address - Street 2:STE 210
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4821
Mailing Address - Country:US
Mailing Address - Phone:501-450-0000
Mailing Address - Fax:501-450-6433
Practice Address - Street 1:2235 DAVE WARD DR STE 108
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7040
Practice Address - Country:US
Practice Address - Phone:501-450-0000
Practice Address - Fax:501-450-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
ARAR208733336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2174625OtherPK