Provider Demographics
NPI:1184661589
Name:BROAD AVENUE PHARMACY LLC
Entity Type:Organization
Organization Name:BROAD AVENUE PHARMACY LLC
Other - Org Name:THOMPSON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-944-6139
Mailing Address - Street 1:2329 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-1979
Mailing Address - Country:US
Mailing Address - Phone:814-943-1310
Mailing Address - Fax:814-943-2841
Practice Address - Street 1:2329 BROAD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-1979
Practice Address - Country:US
Practice Address - Phone:814-943-1310
Practice Address - Fax:814-943-2841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410249L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019655640001Medicaid
2086603OtherPK
4948340001Medicare NSC