Provider Demographics
NPI:1205849221
Name:SCPG MISSISSIPPI LLC
Entity Type:Organization
Organization Name:SCPG MISSISSIPPI LLC
Other - Org Name:CRANFORDS DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEP
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-258-4399
Mailing Address - Street 1:PO BOX 34407 PMP 53760
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-4420
Mailing Address - Country:US
Mailing Address - Phone:501-534-4459
Mailing Address - Fax:501-534-4460
Practice Address - Street 1:121 W. MAIN ST
Practice Address - Street 2:
Practice Address - City:SEMINARY
Practice Address - State:MS
Practice Address - Zip Code:39479
Practice Address - Country:US
Practice Address - Phone:601-722-3291
Practice Address - Fax:601-722-3264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS007293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00031143Medicaid
2050516OtherPK
4206390001Medicare NSC