Provider Demographics
NPI:1598933434
Name:BROAD STREET PHARMACY INC
Entity Type:Organization
Organization Name:BROAD STREET PHARMACY INC
Other - Org Name:BROAD STREET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REZA
Authorized Official - Middle Name:
Authorized Official - Last Name:GHADERI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:703-307-2139
Mailing Address - Street 1:450 W BROAD ST
Mailing Address - Street 2:STE 120
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-3340
Mailing Address - Country:US
Mailing Address - Phone:703-533-9013
Mailing Address - Fax:703-533-9015
Practice Address - Street 1:450 W BROAD ST
Practice Address - Street 2:STE 120 B
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-3340
Practice Address - Country:US
Practice Address - Phone:703-533-9013
Practice Address - Fax:703-533-9015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02010042163336C0003X
3336C0004X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106340OtherPK