Healthcare Provider Details

I. General information

NPI: 1598933434
Provider Name (Legal Business Name): BROAD STREET PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W BROAD ST STE 120 B
FALLS CHURCH VA
22046-3340
US

IV. Provider business mailing address

450 W BROAD ST STE 120
FALLS CHURCH VA
22046-3340
US

V. Phone/Fax

Practice location:
  • Phone: 703-533-9013
  • Fax: 703-533-9015
Mailing address:
  • Phone: 703-533-9013
  • Fax: 703-533-9015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number0201004216
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: REZA GHADERI
Title or Position: OWNER
Credential: RPH
Phone: 703-307-2139