Provider Demographics
NPI:1679651186
Name:BOONEVILLE COMMUNITY PHARMACY OF MSINC
Entity Type:Organization
Organization Name:BOONEVILLE COMMUNITY PHARMACY OF MSINC
Other - Org Name:BOONEVILLE COMMUNITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-728-1951
Mailing Address - Street 1:206 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2702
Mailing Address - Country:US
Mailing Address - Phone:662-728-1951
Mailing Address - Fax:662-728-1873
Practice Address - Street 1:206 N 2ND ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2702
Practice Address - Country:US
Practice Address - Phone:662-728-1951
Practice Address - Fax:662-728-1873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
MS047850113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00330527Medicaid
2520232OtherNCPDP PROVIDER IDENTIFICATION NUMBER
MS00330527Medicaid