Provider Demographics
NPI:1881233187
Name:BROADWAY PHARMACY CORPORATION
Entity Type:Organization
Organization Name:BROADWAY PHARMACY CORPORATION
Other - Org Name:VINCENT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-693-5860
Mailing Address - Street 1:9117 TROPICO DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-6734
Mailing Address - Country:US
Mailing Address - Phone:619-600-7246
Mailing Address - Fax:
Practice Address - Street 1:10225 AUSTIN DR STE 103
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91978-1521
Practice Address - Country:US
Practice Address - Phone:619-825-7733
Practice Address - Fax:619-825-7734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-03
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy