Provider Demographics
NPI:1902945587
Name:BROADWAY PHARMACY INC.
Entity Type:Organization
Organization Name:BROADWAY PHARMACY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:YOXEY
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:719-545-0430
Mailing Address - Street 1:101 COLORADO AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-4213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-4213
Practice Address - Country:US
Practice Address - Phone:719-545-0430
Practice Address - Fax:719-562-8936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CO10400000053336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0605569OtherOTHER ID NUMBER
CO03118007Medicaid
CO03118007Medicaid