Healthcare Provider Details

I. General information

NPI: 1245421742
Provider Name (Legal Business Name): RYAN RICHARD BRIDGE PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5180 W IRLO BRONSON MEMORIAL HWY
KISSIMMEE FL
34746-5346
US

IV. Provider business mailing address

715 E LIVINGSTON ST
ORLANDO FL
32803-5711
US

V. Phone/Fax

Practice location:
  • Phone: 407-589-2120
  • Fax:
Mailing address:
  • Phone: 352-256-3629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberPS42424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: