Healthcare Provider Details

I. General information

NPI: 1588215040
Provider Name (Legal Business Name): SCPG MISSISSIPPI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2019
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1068 HWY 61 N
TUNICA MS
38676
US

IV. Provider business mailing address

PO BOX 7791
LITTLE ROCK AR
72217-7791
US

V. Phone/Fax

Practice location:
  • Phone: 662-363-1540
  • Fax: 662-363-6706
Mailing address:
  • Phone: 501-258-4399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: GALEN PERKINS
Title or Position: MEMBER
Credential:
Phone: 501-258-4399