MEDICARE: THE BROADWAY GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist

General Provider Information

NPI Number	:	1730489287
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BROADWAY GROUP, LLC

Provider Business Mailing Address
First Line	:	904 LEE BLVD
Second Line	:	SUITE 108
City	:	LEHIGH ACRES
State	:	FL
Zip	:	33936-4953
Country	:	US
Telephone Number	:	239-368-9994
Fax Number	:

Provider Business Practice Location Address
First Line	:	3822 BROADWAY
Second Line	:	SUITE C
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8148
Country	:	US
Telephone Number	:	239-274-3004
Fax Number	:

Authorized Official
Title or Position	:	MMBR
Name	:	MRS. KRISTEN J TOUHEY
Credential	:
Telephone Number	:	239-368-9994

Provider Enumeration Date	:	11/01/2010
Last Update Date	:	11/01/2010

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Directions to “THE BROADWAY GROUP, LLC ” Practice Location

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