Provider Demographics
NPI:1417948738
Name:NELSON L SHOWALTER TA BROADWAY DRUG CENTER
Entity Type:Organization
Organization Name:NELSON L SHOWALTER TA BROADWAY DRUG CENTER
Other - Org Name:BROADWAY DRUG CENTER, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHOWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:540-896-3251
Mailing Address - Street 1:169 E SPRINGBROOK RD
Mailing Address - Street 2:PO BOX 245
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-9526
Mailing Address - Country:US
Mailing Address - Phone:540-896-3251
Mailing Address - Fax:540-896-5411
Practice Address - Street 1:169 E SPRINGBROOK RD
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-9526
Practice Address - Country:US
Practice Address - Phone:540-896-3251
Practice Address - Fax:540-896-5411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0139073000Medicaid
WV0139073000Medicaid
00002FMedicare ID - Type UnspecifiedTRAILBLAZER