Provider Demographics
NPI:1124180526
Name:BROADWAY INC.
Entity Type:Organization
Organization Name:BROADWAY INC.
Other - Org Name:BROADWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:GUS
Authorized Official - Last Name:SOTIRIOU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:801-363-3939
Mailing Address - Street 1:242 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2419
Mailing Address - Country:US
Mailing Address - Phone:801-363-3939
Mailing Address - Fax:
Practice Address - Street 1:242 E BROADWAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2419
Practice Address - Country:US
Practice Address - Phone:801-363-3939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1173051703183500000X, 1835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Not Answered1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========003Medicaid
UT4602199Medicare UPIN