Basic Information
| Provider Information | |||||||||
| NPI: | 1003144262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADWATER | ||||||||
| FirstName: | CARNEY | ||||||||
| MiddleName: | JERROD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 356 SENECA TRL | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 370 SENECA TRL | ||||||||
| Address2: | |||||||||
| City: | RONCEVERTE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249701340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046451890 | ||||||||
| FaxNumber: | 3046451891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2009 | ||||||||
| LastUpdateDate: | 11/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | RP0007192 | WV | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.