Provider Demographics
NPI:1104217165
Name:BROADWAY PHARMACY CORPORATION
Entity type:Organization
Organization Name:BROADWAY PHARMACY CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO/SEC/DIR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:T
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:619-600-7246
Mailing Address - Street 1:7600 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945
Mailing Address - Country:US
Mailing Address - Phone:619-717-8990
Mailing Address - Fax:619-717-8616
Practice Address - Street 1:7600 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945
Practice Address - Country:US
Practice Address - Phone:619-717-8990
Practice Address - Fax:619-717-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-12
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH 53335333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy