Healthcare Provider Details

I. General information

NPI: 1881233187
Provider Name (Legal Business Name): BROADWAY PHARMACY CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10225 AUSTIN DR STE 103
SPRING VALLEY CA
91978-1521
US

IV. Provider business mailing address

9117 TROPICO DR
LA MESA CA
91941-6734
US

V. Phone/Fax

Practice location:
  • Phone: 619-825-7733
  • Fax: 619-825-7734
Mailing address:
  • Phone: 619-600-7246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: VINCENT T NGUYEN
Title or Position: PRESIDENT
Credential:
Phone: 619-693-5860