Healthcare Provider Details

I. General information

NPI: 1073940334
Provider Name (Legal Business Name): BOONES CREEK PHARMACY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2013
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4729 N ROAN ST STE 2
JOHNSON CITY TN
37615-3886
US

IV. Provider business mailing address

4729 N ROAN ST STE 2
JOHNSON CITY TN
37615-3733
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-0911
  • Fax: 423-283-0990
Mailing address:
  • Phone: 423-283-0911
  • Fax: 423-283-0990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0000002064
License Number StateTN

VIII. Authorized Official

Name: CADEN COX
Title or Position: OWNER/PIC
Credential: PHARMD
Phone: 423-283-0911