Provider Demographics
NPI: | 1770199432 |
---|---|
Name: | BOONES CREEK PHARMACY, INC. |
Entity Type: | Organization |
Organization Name: | BOONES CREEK PHARMACY, INC. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/PIC/SEC&TREAS |
Authorized Official - Prefix: | |
Authorized Official - First Name: | MARK |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GUIMOND |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 423-283-0911 |
Mailing Address - Street 1: | 4729 N ROAN ST STE 2 |
Mailing Address - Street 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 STE 2 |
Practice Address - Street 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: | 2020-09-18 |
Last Update Date: | 2023-04-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 3336L0003X | Suppliers | Pharmacy | Long Term Care Pharmacy |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TN | Q036582 | Medicaid |