Provider Demographics
NPI:1528089596
Name:SOUTH BROAD DRUGS INC
Entity type:Organization
Organization Name:SOUTH BROAD DRUGS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISING RPH
Authorized Official - Prefix:
Authorized Official - First Name:VINODRAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:973-824-3929
Mailing Address - Street 1:1094 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114-2004
Mailing Address - Country:US
Mailing Address - Phone:973-824-3929
Mailing Address - Fax:973-824-9446
Practice Address - Street 1:1094 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-2004
Practice Address - Country:US
Practice Address - Phone:973-824-3929
Practice Address - Fax:973-824-9446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RS003585003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3126528OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NJ4358007Medicaid
3126528OtherNCPDP PROVIDER IDENTIFICATION NUMBER