Provider Demographics
NPI:1255660379
Name:BROADWAY CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:BROADWAY CLINIC PHARMACY INC
Other - Org Name:MEDICINE CABINET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-324-6337
Mailing Address - Street 1:251 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977-1646
Mailing Address - Country:US
Mailing Address - Phone:606-337-3784
Mailing Address - Fax:606-337-3747
Practice Address - Street 1:251 S PINE ST
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977-1646
Practice Address - Country:US
Practice Address - Phone:606-337-3784
Practice Address - Fax:606-337-3747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-19
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP073663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831709OtherNCPDP PROVIDER IDENTIFICATION NUMBER