Healthcare Provider Details

I. General information

NPI: 1710913355
Provider Name (Legal Business Name): BROAD STREET PHARMACY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 W BROAD ST
CHESANING MI
48616-1068
US

IV. Provider business mailing address

1115 W BROAD ST
CHESANING MI
48616-1068
US

V. Phone/Fax

Practice location:
  • Phone: 989-845-9355
  • Fax: 989-845-9356
Mailing address:
  • Phone: 989-845-9355
  • Fax: 989-845-9356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DR. TAMARA ELIZABETH MASON
Title or Position: PRESIDENT
Credential:
Phone: 989-845-9355