Provider Demographics
NPI:1669948162
Name:BROAD AVENUE PHARMACY LLC
Entity type:Organization
Organization Name:BROAD AVENUE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PHAT
Authorized Official - Middle Name:
Authorized Official - Last Name:QUACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-309-4388
Mailing Address - Street 1:1400 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-2332
Mailing Address - Country:US
Mailing Address - Phone:504-309-4388
Mailing Address - Fax:
Practice Address - Street 1:1400 N BROAD ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-2332
Practice Address - Country:US
Practice Address - Phone:504-309-4388
Practice Address - Fax:504-309-4389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-23
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy