Organization
BROAD STREET PHARMACY INC
Active
Other names
BROAD STREET PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
REZA GHADERI RPH (OWNER)
(703) 307-2139
Entity
Organization
Contact information
Practice address
450 W BROAD ST, STE 120 B, FALLS CHURCH, VA 22046-3340
(703) 533-9013
(703) 533-9015
Mailing address
450 W BROAD ST, STE 120, FALLS CHURCH, VA 22046-3340
(703) 533-9013
(703) 533-9015
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
0201004216
VA
3336C0004X
Compounding Pharmacy
—
—
3336S0011X
Specialty Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2106340
PK
—
Enumeration date
02/13/2008
Last updated
05/13/2013
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