Provider Demographics
NPI:1851638522
Name:BOONE, BRIAN W
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:BOONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NIGHT HAWK LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-7419
Mailing Address - Country:US
Mailing Address - Phone:843-819-2122
Mailing Address - Fax:
Practice Address - Street 1:3725 RIVERS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-7038
Practice Address - Country:US
Practice Address - Phone:843-745-8631
Practice Address - Fax:843-747-6841
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11480183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist