Provider Demographics
NPI:1376769869
Name:BROAD ST PHARMACY
Entity Type:Organization
Organization Name:BROAD ST PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER RPH
Authorized Official - Prefix:MR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:SR
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-755-2010
Mailing Address - Street 1:1412 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146
Mailing Address - Country:US
Mailing Address - Phone:215-755-2010
Mailing Address - Fax:215-940-1266
Practice Address - Street 1:1412 S BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-755-2010
Practice Address - Fax:215-940-1266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP414363L333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00121699Medicaid
PA3961047OtherNABP