Provider Demographics
NPI:1467770420
Name:SOUTH BROADWAY PHARMACY
Entity type:Organization
Organization Name:SOUTH BROADWAY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:MANSOUR
Authorized Official - Last Name:SALEH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D,
Authorized Official - Phone:914-965-1000
Mailing Address - Street 1:314 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10705-2049
Mailing Address - Country:US
Mailing Address - Phone:914-965-1000
Mailing Address - Fax:914-965-1002
Practice Address - Street 1:314 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10705-2049
Practice Address - Country:US
Practice Address - Phone:914-965-1000
Practice Address - Fax:914-965-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030085333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03246077Medicaid
NY6479180001Medicare NSC