Provider Demographics
NPI:1720200900
Name:BOONE'S PHARMACY
Entity Type:Organization
Organization Name:BOONE'S PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF PHARMACY
Authorized Official - Phone:318-793-2400
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:511 ULSTER STREET
Mailing Address - City:BOYCE
Mailing Address - State:LA
Mailing Address - Zip Code:71409
Mailing Address - Country:US
Mailing Address - Phone:318-793-2400
Mailing Address - Fax:318-793-9100
Practice Address - Street 1:511 ULSTER STREET
Practice Address - Street 2:
Practice Address - City:BOYCE
Practice Address - State:LA
Practice Address - Zip Code:71409
Practice Address - Country:US
Practice Address - Phone:318-793-2400
Practice Address - Fax:318-793-9100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10751333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1262552Medicaid