Provider Demographics
NPI:1770134611
Name:SCPG TENNESSEE LLC
Entity type:Organization
Organization Name:SCPG TENNESSEE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-258-4399
Mailing Address - Street 1:PO BOX 34407
Mailing Address - Street 2:PMB 53760
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-4407
Mailing Address - Country:US
Mailing Address - Phone:501-534-4459
Mailing Address - Fax:501-534-4460
Practice Address - Street 1:251 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-1736
Practice Address - Country:US
Practice Address - Phone:731-635-2232
Practice Address - Fax:731-635-8939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ054089Medicaid