Provider Demographics
NPI:1780235614
Name:SCPG MISSISSIPPI LLC
Entity type:Organization
Organization Name:SCPG MISSISSIPPI LLC
Other - Org Name:
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 7791
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72217-7791
Mailing Address - Country:US
Mailing Address - Phone:501-258-4399
Mailing Address - Fax:
Practice Address - Street 1:101 W SWEET POTATO ST
Practice Address - Street 2:
Practice Address - City:VARDAMAN
Practice Address - State:MS
Practice Address - Zip Code:38878-9433
Practice Address - Country:US
Practice Address - Phone:662-682-7489
Practice Address - Fax:662-682-9132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy