Provider Demographics
NPI:1215439609
Name:BROADWAY DISCOUNT PHARMACY LLC
Entity type:Organization
Organization Name:BROADWAY DISCOUNT PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:DHADUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-916-7123
Mailing Address - Street 1:4040 SUNSET LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2841
Mailing Address - Country:US
Mailing Address - Phone:201-916-7123
Mailing Address - Fax:
Practice Address - Street 1:1765 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830-3104
Practice Address - Country:US
Practice Address - Phone:863-537-7656
Practice Address - Fax:863-537-7927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-01
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH312163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy