Provider Demographics
NPI:1093993388
Name:BROAD AND GRANGE PHARMACY
Entity Type:Organization
Organization Name:BROAD AND GRANGE PHARMACY
Other - Org Name:BROAD AND GRANGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-228-9007
Mailing Address - Street 1:5751 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-2300
Mailing Address - Country:US
Mailing Address - Phone:215-424-2611
Mailing Address - Fax:215-424-6927
Practice Address - Street 1:5751 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-2300
Practice Address - Country:US
Practice Address - Phone:215-424-2611
Practice Address - Fax:215-424-6927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP4817833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2082477OtherPK