MEDICARE: BRIDGE MEDICAL SERVICES LLC

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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1851857270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDGE MEDICAL SERVICES LLC

Provider Business Mailing Address
First Line	:	PO BOX 1257
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86405-1257
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1955 MCCULLOCH BLVD N # 100
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-5739
Country	:	US
Telephone Number	:	928-230-9812
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. EZEKIEL KEERENG KESITILWE
Credential	:	PHARMD
Telephone Number	:	928-230-9812

Provider Enumeration Date	:	02/11/2019
Last Update Date	:	02/11/2019

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Directions to “BRIDGE MEDICAL SERVICES LLC ” Practice Location

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