Healthcare Provider Details

I. General information

NPI: 1700194578
Provider Name (Legal Business Name): BROADWAY CLINIC PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47454 ROUTE 52
KERMIT WV
25674-8052
US

IV. Provider business mailing address

47454 ROUTE 52
KERMIT WV
25674-8052
US

V. Phone/Fax

Practice location:
  • Phone: 304-393-6905
  • Fax: 304-393-6907
Mailing address:
  • Phone: 304-393-6905
  • Fax: 304-393-6907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License NumberMP0552389
License Number StateWV

VIII. Authorized Official

Name: STEVE WILLIAMS
Title or Position: PRESIDENT
Credential:
Phone: 606-324-6337