Provider Demographics
NPI:1700194578
Name:BROADWAY CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:BROADWAY CLINIC PHARMACY INC
Other - Org Name:MEDICINE CABINET PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-324-6337
Mailing Address - Street 1:47454 ROUTE 52
Mailing Address - Street 2:
Mailing Address - City:KERMIT
Mailing Address - State:WV
Mailing Address - Zip Code:25674-8052
Mailing Address - Country:US
Mailing Address - Phone:304-393-6905
Mailing Address - Fax:304-393-6907
Practice Address - Street 1:47454 ROUTE 52
Practice Address - Street 2:
Practice Address - City:KERMIT
Practice Address - State:WV
Practice Address - Zip Code:25674-8052
Practice Address - Country:US
Practice Address - Phone:304-393-6905
Practice Address - Fax:304-393-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVMP05523893336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
5055290OtherNCPDP PROVIDER IDENTIFICATION NUMBER