Provider Demographics
NPI:1598201436
Name:SSCP1 LLC
Entity Type:Organization
Organization Name:SSCP1 LLC
Other - Org Name:MEDICAL ARTS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:
Authorized Official - Last Name:VEERANKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-709-5532
Mailing Address - Street 1:1169 EASTERN PARKWAY
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1462
Mailing Address - Country:US
Mailing Address - Phone:502-709-5532
Mailing Address - Fax:502-371-6659
Practice Address - Street 1:1169 EASTERN PARKWAY
Practice Address - Street 2:SUITE 1110
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1462
Practice Address - Country:US
Practice Address - Phone:502-709-5532
Practice Address - Fax:502-371-6659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-17
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336C0003X
KYP07800333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2163762OtherPK
KY7100536810Medicaid