Provider Demographics
NPI:1730489287
Name:THE BROADWAY GROUP, LLC
Entity Type:Organization
Organization Name:THE BROADWAY GROUP, LLC
Other - Org Name:THE MEDICINE MAN DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MMBR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TOUHEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-368-9994
Mailing Address - Street 1:904 LEE BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-4953
Mailing Address - Country:US
Mailing Address - Phone:239-368-9994
Mailing Address - Fax:
Practice Address - Street 1:3822 BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8148
Practice Address - Country:US
Practice Address - Phone:239-274-3004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty