Provider Demographics
NPI:1508430265
Name:BROAD SPECIALTY PHARMACY
Entity Type:Organization
Organization Name:BROAD SPECIALTY PHARMACY
Other - Org Name:BROAD SPECIALTY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:FAHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-339-2273
Mailing Address - Street 1:737 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-3942
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:737 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3942
Practice Address - Country:US
Practice Address - Phone:201-339-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-18
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy