Provider Demographics
NPI:1891896213
Name:BROADWAY DOWNTOWN PHARMACY INC.
Entity Type:Organization
Organization Name:BROADWAY DOWNTOWN PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-925-4888
Mailing Address - Street 1:373 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-3926
Mailing Address - Country:US
Mailing Address - Phone:212-925-4888
Mailing Address - Fax:212-925-4917
Practice Address - Street 1:373 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-3926
Practice Address - Country:US
Practice Address - Phone:212-925-4888
Practice Address - Fax:212-925-4917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0223843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01539697Medicaid
NY01539697Medicaid