Provider Demographics
NPI:1720082340
Name:BROAD & LEHIGH PHARMACY, INC
Entity Type:Organization
Organization Name:BROAD & LEHIGH PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:215-228-9007
Mailing Address - Street 1:1300 W LEHIGH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19132-2701
Mailing Address - Country:US
Mailing Address - Phone:215-228-9007
Mailing Address - Fax:215-228-9099
Practice Address - Street 1:1300 W LEHIGH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19132-2701
Practice Address - Country:US
Practice Address - Phone:215-228-9007
Practice Address - Fax:215-228-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPP415177L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015875230001Medicaid
PA4981530001Medicare NSC