1831435452 NPI number — SCPG ARKANSAS LLC

Table of content: (NPI 1831435452)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831435452 NPI number — SCPG ARKANSAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SCPG ARKANSAS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EXPRESS RX AT NATIONAL PARK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1831435452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 34407 PMB 53760
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72203-4420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-603-7409
Provider Business Mailing Address Fax Number:
501-321-1201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 SAWTOOTH OAK STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-623-2222
Provider Business Practice Location Address Fax Number:
870-245-1790
Provider Enumeration Date:
12/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
PERKINS
Authorized Official First Name:
GALEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
501-259-4399

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  20697 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 196748407 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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