Provider Demographics
NPI:1548395791
Name:SCPG TENNESSEE LLC
Entity Type:Organization
Organization Name:SCPG TENNESSEE LLC
Other - Org Name:EXPRESS RX OF LEWISBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-259-4399
Mailing Address - Street 1:PO BOX 34407 PBP 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 1:521 W COMMERCE ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091
Practice Address - Country:US
Practice Address - Phone:931-359-2534
Practice Address - Fax:931-359-4096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336C0004X
TN00000006193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3511622Medicaid
2095725OtherPK
0330780003Medicare NSC