Provider Demographics
NPI:1932323342
Name:BROADWAY DRUG STORE INC
Entity Type:Organization
Organization Name:BROADWAY DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RITA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-765-7701
Mailing Address - Street 1:2027 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550-4635
Mailing Address - Country:US
Mailing Address - Phone:409-765-7701
Mailing Address - Fax:409-762-2545
Practice Address - Street 1:2027 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550-4635
Practice Address - Country:US
Practice Address - Phone:409-765-7701
Practice Address - Fax:409-762-2545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX018683336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4520739OtherNABP NUMBER
TXTX0012Medicaid