Provider Demographics
NPI:1710913355
Name:BROAD STREET PHARMACY, INC
Entity Type:Organization
Organization Name:BROAD STREET PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TOMAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-845-9355
Mailing Address - Street 1:1115 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-1068
Mailing Address - Country:US
Mailing Address - Phone:989-845-9355
Mailing Address - Fax:989-845-9356
Practice Address - Street 1:1115 W BROAD ST
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1068
Practice Address - Country:US
Practice Address - Phone:989-845-9355
Practice Address - Fax:989-845-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2366498Medicaid
MI6318420001Medicare NSC