Provider Demographics
NPI:1912992033
Name:GRIFFIN BROADMOOR PHARMACY INC
Entity Type:Organization
Organization Name:GRIFFIN BROADMOOR PHARMACY INC
Other - Org Name:BROADMOOR PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:219-836-8585
Mailing Address - Street 1:110 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1520
Mailing Address - Country:US
Mailing Address - Phone:219-836-8585
Mailing Address - Fax:219-836-5657
Practice Address - Street 1:110 RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1520
Practice Address - Country:US
Practice Address - Phone:219-836-8585
Practice Address - Fax:219-836-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN60003614A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0460000001Medicare ID - Type Unspecified