Provider Demographics
NPI:1114062932
Name:THE BROADWAY COMPANY
Entity type:Organization
Organization Name:THE BROADWAY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:406-538-8128
Mailing Address - Street 1:210 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTOWN
Mailing Address - State:MT
Mailing Address - Zip Code:59457-2702
Mailing Address - Country:US
Mailing Address - Phone:406-538-8128
Mailing Address - Fax:406-535-5331
Practice Address - Street 1:210 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTOWN
Practice Address - State:MT
Practice Address - Zip Code:59457-2702
Practice Address - Country:US
Practice Address - Phone:406-538-8128
Practice Address - Fax:406-535-5331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT111183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty