Provider Demographics
NPI:1245915040
Name:EAST BROADWAY PHARMACY LLC
Entity type:Organization
Organization Name:EAST BROADWAY PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-416-4439
Mailing Address - Street 1:3525 BROADWAY ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581-4379
Mailing Address - Country:US
Mailing Address - Phone:281-416-4439
Mailing Address - Fax:
Practice Address - Street 1:1712 N VELASCO ST STE D
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-3195
Practice Address - Country:US
Practice Address - Phone:281-416-4439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy