Provider Demographics
NPI:1073940334
Name:BOONES CREEK PHARMACY, INC.
Entity Type:Organization
Organization Name:BOONES CREEK PHARMACY, INC.
Other - Org Name:BOONES CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GUIMOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:423-283-0911
Mailing Address - Street 1:4729 N ROAN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3886
Mailing Address - Country:US
Mailing Address - Phone:423-283-0911
Mailing Address - Fax:423-283-0990
Practice Address - Street 1:4729 N ROAN ST
Practice Address - Street 2:STE 2
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-3886
Practice Address - Country:US
Practice Address - Phone:423-283-0911
Practice Address - Fax:423-283-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-02
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TN00000020643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2142795OtherPK