Provider Demographics
NPI:1194839183
Name:BOONES PHARMACY INC
Entity Type:Organization
Organization Name:BOONES PHARMACY INC
Other - Org Name:BOONE'S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-799-4566
Mailing Address - Street 1:937 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POPLARVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39470-3111
Mailing Address - Country:US
Mailing Address - Phone:601-795-4566
Mailing Address - Fax:601-795-4571
Practice Address - Street 1:937 S MAIN ST
Practice Address - Street 2:
Practice Address - City:POPLARVILLE
Practice Address - State:MS
Practice Address - Zip Code:39470-3111
Practice Address - Country:US
Practice Address - Phone:601-795-4566
Practice Address - Fax:601-795-4571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MS00935/1.13336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00039543Medicaid
2043395OtherPK
2043395OtherPK