Provider Demographics
NPI:1285676064
Name:BROADWAY PHARMACY INC
Entity Type:Organization
Organization Name:BROADWAY PHARMACY INC
Other - Org Name:WYCKOFF DRUGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISING PHRMCST/MGR
Authorized Official - Prefix:
Authorized Official - First Name:JOJY
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:718-431-3311
Mailing Address - Street 1:1226 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-2906
Mailing Address - Country:US
Mailing Address - Phone:718-443-1331
Mailing Address - Fax:718-443-9438
Practice Address - Street 1:1226 BROADWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-2906
Practice Address - Country:US
Practice Address - Phone:718-443-1331
Practice Address - Fax:718-443-9438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
NY0254043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02269616Medicaid
2061851OtherPK
2061851OtherPK