Provider Demographics
NPI:1467567404
Name:WILSON PHARMACY INC
Entity Type:Organization
Organization Name:WILSON PHARMACY INC
Other - Org Name:MOUNTAIN STATES PHARMACY AT BOONES CREEK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AVP REIMBURSEMENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-431-1941
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-926-6154
Mailing Address - Fax:423-926-7965
Practice Address - Street 1:2685 BOONES CREEK RD
Practice Address - Street 2:STE 105
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-4722
Practice Address - Country:US
Practice Address - Phone:423-282-6337
Practice Address - Fax:423-282-5264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TN43073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
2095039OtherPK
TN9440037Medicaid
TN9440037Medicaid