Provider Demographics
NPI:1104426410
Name:BROADWAY, JOSHUA JEFFREY
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JEFFREY
Last Name:BROADWAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 WINROSE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-2582
Mailing Address - Country:US
Mailing Address - Phone:904-568-6225
Mailing Address - Fax:
Practice Address - Street 1:845 DURBIN PAVILION DR
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-4119
Practice Address - Country:US
Practice Address - Phone:904-417-9675
Practice Address - Fax:904-417-9671
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS43893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist