Provider Demographics
NPI:1528463775
Name:SCPG ARKANSAS LLC
Entity type:Organization
Organization Name:SCPG ARKANSAS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
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:870-850-0159
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:72203-0524
Mailing Address - Country:US
Mailing Address - Phone:870-850-0159
Mailing Address - Fax:870-850-0177
Practice Address - Street 1:3006 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-4803
Practice Address - Country:US
Practice Address - Phone:870-850-0159
Practice Address - Fax:870-850-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR207253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198211407Medicaid
0424414OtherNCPDP