Provider Demographics
NPI:1386729317
Name:SLC HOLDINGS
Entity type:Organization
Organization Name:SLC HOLDINGS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENE'
Authorized Official - Middle Name:
Authorized Official - Last Name:LANDRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-327-5400
Mailing Address - Street 1:2219 5TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2211
Mailing Address - Country:US
Mailing Address - Phone:662-327-5400
Mailing Address - Fax:662-327-5225
Practice Address - Street 1:2219 5TH ST N
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2211
Practice Address - Country:US
Practice Address - Phone:662-327-5400
Practice Address - Fax:662-327-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
MS01383/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0030014Medicaid
2144373OtherPK
MS00040353Medicaid
MS00030014Medicaid