1720082340 NPI number — BROAD & LEHIGH PHARMACY, INC

Table of content: (NPI 1720082340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720082340 NPI number — BROAD & LEHIGH PHARMACY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROAD & LEHIGH PHARMACY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720082340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 W LEHIGH AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19132-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-228-9007
Provider Business Mailing Address Fax Number:
215-228-9099

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 W LEHIGH AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19132-2701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-228-9007
Provider Business Practice Location Address Fax Number:
215-228-9099
Provider Enumeration Date:
06/10/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SNYDER
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
HOWARD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
215-228-9007

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PP415177L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0015875230001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".