Provider Demographics
NPI:1255620464
Name:BROADWAY CLINIC PHARMACY INC
Entity type:Organization
Organization Name:BROADWAY CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-225-3784
Mailing Address - Street 1:698 E NEW CIRCLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-2948
Mailing Address - Country:US
Mailing Address - Phone:859-225-3784
Mailing Address - Fax:859-381-0277
Practice Address - Street 1:698 E NEW CIRCLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-2948
Practice Address - Country:US
Practice Address - Phone:859-225-3784
Practice Address - Fax:859-381-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYP074193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1832357OtherNCPDP PROVIDER IDENTIFICATION NUMBER