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?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ036582Medicaid