Provider Demographics
NPI:1346263324
Name:SCPG KENTUCKY LLC
Entity Type:Organization
Organization Name:SCPG KENTUCKY LLC
Other - Org Name:EXPRESS RX OF TAYLORSVILLE
Other - Org Type:Doing Business As
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:501-259-4399
Mailing Address - Street 1:PO BOX 34407 PMP 53760
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-4420
Mailing Address - Country:US
Mailing Address - Phone:501-534-4459
Mailing Address - Fax:501-534-4460
Practice Address - Street 1:847 TAYLORSVILLE RD
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40071
Practice Address - Country:US
Practice Address - Phone:502-477-2267
Practice Address - Fax:502-477-2283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SC PHARMACY GROUP OPCO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
KYP070973336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100176430Medicaid
KY90011081Medicaid
KY54023528Medicaid
0924880001Medicare NSC