Provider Demographics
NPI:1952864951
Name:BROAD STREET PHARMACY, INC
Entity Type:Organization
Organization Name:BROAD STREET PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-845-9355
Mailing Address - Street 1:1115 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CHESANING
Mailing Address - State:MI
Mailing Address - Zip Code:48616-1068
Mailing Address - Country:US
Mailing Address - Phone:989-845-9355
Mailing Address - Fax:989-845-9356
Practice Address - Street 1:1115 W BROAD ST
Practice Address - Street 2:
Practice Address - City:CHESANING
Practice Address - State:MI
Practice Address - Zip Code:48616-1068
Practice Address - Country:US
Practice Address - Phone:989-845-9355
Practice Address - Fax:989-845-9356
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROAD STREET PHARMACY, LTC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy