Provider Demographics
NPI:1447480702
Name:BROADWAY CLINIC PHARMACY INC
Entity type:Organization
Organization Name:BROADWAY CLINIC PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-286-2035
Mailing Address - Street 1:230 STATE HIGHWAY 2
Mailing Address - Street 2:
Mailing Address - City:OLIVE HILL
Mailing Address - State:KY
Mailing Address - Zip Code:41164-4513
Mailing Address - Country:US
Mailing Address - Phone:606-286-2035
Mailing Address - Fax:606-286-0156
Practice Address - Street 1:230 STATE HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164-4513
Practice Address - Country:US
Practice Address - Phone:606-286-2035
Practice Address - Fax:606-286-0156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100620930Medicaid
1831381OtherNCPDP PROVIDER IDENTIFICATION NUMBER