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General NPI Number Information
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NPI Number | 1376769869
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Entity Type | Organization
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Legal Business Name | BROAD ST PHARMACY
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/21/2007
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Provider Practice Location Address
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Address Line | 1412 S BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19146
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Country | US
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Telephone | 215-755-2010
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Fax | 215-940-1266
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Provider Business Mailing Address
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Address Line | 1412 S BROAD ST
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City | PHILADELPHIA
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State | PA
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Zip | 19146
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Country | US
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Telephone | 215-755-2010
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Fax | 215-940-1266
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Authorized Official
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Title or Position | OWNER RPH
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Name | MR. MORRIS J WHITE SR.
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Credential | RPH
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Telephone | 215-755-2010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | PP414363L
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License Number State | PA
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