Provider Demographics
NPI:1821082504
Name:BROADWAY LTC PHARMACY, INC.
Entity Type:Organization
Organization Name:BROADWAY LTC PHARMACY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-364-2418
Mailing Address - Street 1:4545 HARLIN DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-9716
Mailing Address - Country:US
Mailing Address - Phone:916-364-2416
Mailing Address - Fax:
Practice Address - Street 1:3330 BROADWAY
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2840
Practice Address - Country:US
Practice Address - Phone:916-452-8022
Practice Address - Fax:916-452-6326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPHY44334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA443340Medicaid