Healthcare Provider Details

I. General information

NPI: 1205849221
Provider Name (Legal Business Name): SCPG MISSISSIPPI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W. MAIN ST
SEMINARY MS
39479
US

IV. Provider business mailing address

PO BOX 34407 PMP 53760
LITTLE ROCK AR
72203-4420
US

V. Phone/Fax

Practice location:
  • Phone: 601-722-3291
  • Fax: 601-722-3264
Mailing address:
  • Phone: 501-534-4459
  • Fax: 501-534-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number00729
License Number StateMS

VIII. Authorized Official

Name: UMAR FAROOQ
Title or Position: PRESIDENT
Credential:
Phone: 501-392-8680