Provider Demographics
NPI:1104217165
Name:BROADWAY PHARMACY CORPORATION
Entity Type:Organization
Organization Name:BROADWAY PHARMACY CORPORATION
Other - Org Name:BROADWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:619-600-7246
Mailing Address - Street 1:9117 TROPICO DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6734
Mailing Address - Country:US
Mailing Address - Phone:619-600-7246
Mailing Address - Fax:
Practice Address - Street 1:7581 BROADWAY
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1605
Practice Address - Country:US
Practice Address - Phone:619-717-8990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 53335333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy