Provider Demographics
NPI:1982718961
Name:BROADWAY CLINIC PHARMACY INC
Entity Type:Organization
Organization Name:BROADWAY CLINIC PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEMASTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-789-9988
Mailing Address - Street 1:607 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1250
Mailing Address - Country:US
Mailing Address - Phone:606-789-9988
Mailing Address - Fax:606-789-7619
Practice Address - Street 1:607 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240
Practice Address - Country:US
Practice Address - Phone:606-789-9988
Practice Address - Fax:606-789-7619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
KYP078413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54008610Medicaid
2031830OtherPK
2031830OtherPK