MEDICARE: BRIDGEPORT PHARMACY INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	054015048	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2021465	OTHER		PK

General Provider Information

NPI Number	:	1437206588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGEPORT PHARMACY INC

Provider Business Mailing Address
First Line	:	3201 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3501
Country	:	US
Telephone Number	:	312-791-9000
Fax Number	:	312-791-9650

Provider Business Practice Location Address
First Line	:	3201 S WALLACE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3501
Country	:	US
Telephone Number	:	312-791-9000
Fax Number	:	312-791-9650

Authorized Official
Title or Position	:	PHARMACY MANAGER
Name	:	SNEHAL BHAVSAR
Credential	:
Telephone Number	:	312-791-9000

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	02/10/2021

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Directions to “BRIDGEPORT PHARMACY INC ” Practice Location

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