Provider Demographics
NPI:1508904590
Name:LEWISBURG COMPOUNDING CENTER
Entity Type:Organization
Organization Name:LEWISBURG COMPOUNDING CENTER
Other - Org Name:MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:THIRD PARTY PLAN COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DENA
Authorized Official - Middle Name:
Authorized Official - Last Name:FERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-993-6000
Mailing Address - Street 1:733 W COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-3231
Mailing Address - Country:US
Mailing Address - Phone:931-359-1383
Mailing Address - Fax:931-359-1386
Practice Address - Street 1:733 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-3231
Practice Address - Country:US
Practice Address - Phone:931-359-1383
Practice Address - Fax:931-359-1386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1752333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1455014Medicaid
4423098OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TNBT4027694OtherDEA #
4423098OtherOTHER ID NUMBER-COMMERCIAL NUMBER
TN5648Medicare PIN